‘HAES’, I’m sure you’ve heard of it.
But what exactly is Health At Every Size?
There’s ever-growing concern among health professionals and the general public alike about the rising prevalence of overweight and obesity and its link to several physical and psychological health complications.
The traditional approach to health care has emphasized the role of body weight as the main determinant of health. This weight-normative approach rests on the assumption that weight and disease are linearly related – i.e., that the higher the body weight the worse the disease.
This weight-normative approach emphasizes personal responsibility for healthy lifestyle choices and the maintenance of healthy body weight. And, because of this, the focus is primarily on weight loss and weight management as the method for preventing and treating health problems.
Despite how pervasive this approach is in modern society, those who oppose the weight-normative approach argue that the scientific evidence does not support such a focus on weight loss to improve health and obesity.
There are three broad reasons for this.
- There’s actually no evidence showing that a higher BMI is a cause of poor health. Only associations exist between these variables, and, because of this, we can’t actually rule out the possibility that other variables are driving this link.
- The success rates of restrictive weight loss diets are extremely poor; the vast majority of people regain almost all weight lost through a diet.
- A weight- and diet-centric focus is a contributor to several poor health outcomes, including eating disorders and weight stigma.
So, there has been quite a bit of concern that this weight-normative approach is not only ineffective at producing thinner, healthier bodies, but that it is also harmful by contributing to food and body preoccupation, repeated cycles of weight loss and regain, and distraction from other personal health behaviours 1Tylka, T. L., Annunziato, R. A., Burgard, D., Daníelsdóttir, S., Shuman, E., Davis, C., & Calogero, R. M. (2014). The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss. Journal of Obesity, 1-18.
Perhaps a newer approach is needed?
Table of Contents
The Emergence of Health at Every Size
Enter the Health at Every Size (HAES) movement.
I’m sure you’ve hear of it, but what’s the meaning behind HAES?
HAES is a paradigm that entirely shifts the focus away from weight management and onto health promotion 2Bacon, L. (2010). Health at Every Size Dallas, USA: Benbella Books.
The goal of HAES is to encourage and foster various health behaviours for people of all sizes – weight or weight loss is not the focus nor the proxy for health, particularly for those whose weight is not at the statistical extremes.
Principles of Health at Every Size
The philosophy of HAES works off many different principles. These can be usefully categorized into the following.
1. Body Acceptance
“If shame was an effective motivator, then there wouldn’t be many fat people”
There’s little – if any – evidence to suggest that making people feel bad about their body will encourage health behaviour and weight loss.
In fact, the opposite is true.
A key principle of the HAES approach is to therefore teach people to value, respect, and accept their body for what is and what it can do. Emphasis is placed on nurturing people to respect and appreciate body diversity while also rejecting the notion that specific body shapes are idealized or superior 3Bacon, L., & Aphramor, L. (2011). Weight science: evaluating the evidence for a paradigm shift. Nutrition Journal, 10, 2-13.
The latter point is particularly important, because there’s conclusive evidence to suggest that those who believe that certain body types are superior than others are the ones most likely to develop an eating disorder.
2. Intuitive eating
Weight loss diets don’t work.
The evidence is pretty clear on this.
So, why then would we encourage weight loss diets if they not only produce the intended result, but they also come with many risks, like eating disorders?
The HAES movement is strong about this, and instead it encourages intuitive eating.
Intuitive eating is an adaptive style of eating that is characterized by having a strong connection with internal hunger and satiety cues 4Tylka, T. L., & Kroon Van Diest, A. M. (2013). The Intuitive Eating Scale–2: Item refinement and psychometric evaluation with college women and men. Journal of Counseling Psychology, 60, 137-153.
In other words, it involves eating when you’re hungry and stopping when you’re full – or, more broadly, honouring your body for what it needs. There are no external rules imposed like weight loss diets.
Intuitive eating doesn’t just involve eating based on body signals; rather, it involves teaching people to value food for nutritional, psychological, sensual, and cultural reasons. It also involves recognising that food serves a variety of purposes, including energy, stamina, and taste.
3. Active Embodiment
Exercise is crucial for good health, and HAES recognises this.
A key HAES principle is active embodiment, which involves encouraging people of all shapes and sizes to build physical activity into their daily routine and focuses on helping people find enjoyable ways of being active.
Active embodiment doesn’t mean engaging in stringent exercise to meet specific shape- or weight-related goals.
Rather, the goal is to promote well-being, self-care, and mind-body-connection through regular, healthy movement
4. Respectful Care
A final principle of HAES involves respectful care.
This means that we, as professionals, should acknowledge our biases and word to end weight discrimination/prejudice, weight stigma, and weight bias.
We need to provide information and services from an understanding that socio-economic status, race, gender, sexual orientation, age, and other identities impact weight stigma, and support environments that address these inequities 5Provencher, V., Bégin, C., Tremblay, A., Mongeau, L., Boivin, S., & Lemieux, S. (2007). Short‐Term Effects of a “Health‐At‐Every‐Size” Approach on Eating Behaviors and Appetite Ratings. Obesity, 15, 957-966.
Is There Evidence Supporting HAES?
We’ve covered the reasons, theory, and principles behind the HAES philosophy, but what does the evidence say.
Does HAES do as intended?
In other words, does it promote health?
The best way to answer this question is to review the available randomized controlled trials of HAES-based interventions.
Fortunately, there have been a few of these trials conducted, so we can get a sense of evidence 6Bacon, L., & Aphramor, L. (2011). Weight science: evaluating the evidence for a paradigm shift. Nutrition Journal, 10, 2-13.
The evidence is preliminary, but promising. That is, HAES interventions have been shown to result in the following health outcomes:
- Weight stability
- Improved body image
- Enhanced self-esteem
- Reduced binge eating
- Improved quality of life
- Reduced blood pressure
- Reduced cholesterol
While this sounds promising, I will stress point out that most existing trials of HAES interventions present with some biases.
For example, most trials only analyse those who completed the intervention, and so it’s likely that the improvements observed are overestimated or exaggerated. In addition, there is the problem of blinding; researchers who are assessing the health outcomes often know which group the participant belongs to.
This is a source of bias that has the potential to produce misleading results.
So Where Does HAES Stand?
HAES has done a wonderful job at encouraging health behaviour for all people, irrespective of weight, size, and shape.
The shift away from weight loss and onto health promotion is sorely needed in a society that values thin and muscular ideals. We know that such ideals are an important cause of eating disorders.
There’s still a lot more we need to learn about HAES, including the longer-term effects of these interventions as well as identification of how, for whom, and through what mechanisms HAES-based approaches work.
Despite this, it’s an exciting area that instilling a lot of confidence in people.
References
I’ve struggled with the HAES concept in the past and was even pretty strongly opposed at one point. After attending a seminar on the HAES movement, my mind was opened and I’ve done so much more reading on the topic. It’s now something I regularly preach to my clients – body acceptance. We strive for optimal health but not at the cost of other variables. As always, THANK YOU for putting out such amazing content.
Thanks Shana! I agree, I think the movement contains very valuable principles that can benefit almost everyone!
Thanks for your kind words Shana.
1. Weight loss diets don’t work because of poor healthcare management, poor patient management, fad diets, poor scientific behavioural knowledge, poor nutrition education and the main – almost ZERO help with weight maintenance management from dietitians, phycisians and “weight loss programms”. It doesn’t mean that we should just say – ok, we can’t do anything, we don’t have control over our lifes and bodies and let obesity win, let people be obese.
2. There’s actually no evidence showing that a higher BMI is a cause of poor health (c) It is very, VERY disputable. To the some extent – yes, maybe. It is not a big deal if someone is slightly overweight (although it is very individual). But, cmon there’s no doubt that if someone is morbidly obese or even 2 class obese it’s VERY likely that it would have negative impact on his health. And it is pretty hard to enjoy life when going upstairs is hard challenge, no matter how freacking much you love your body. And there’s still such things like leptin resistance and extreme hunger which are developed because of obesity (not vice versa). Adipose tissue produce hormones and if you have to much it, it ruins homeostasis, it is stupid to argue with it. To be overweight isn’t good for quality of life, no matter love your body or not. It is not enjoyable to be physically active when you’re morbidly obese. And it
3. If you’re saying that there’s no causation between BMI and health (which is true only to some extent), then IE have even less evidence. There’s no actually evidence that intuitive eating works for overweight people, it wasn’t researched properly in clinical trials. Even fad diets are more researched There’s shit tons of correlation studies (with a huge heterogenity) on of IE that doesn’t prove anything and few very little RCTs that researched just some soft points like “body image”. Yeah intuitive eaters tend to be slimmer and healthier psychologically, because they were already healthy psycholodically and had good hunger/satiety balance, so they don’t have to do anything else and restrict themself. And btw this “intuitive eating” has nothing to do with 10 principles that are promoting from every corner of the internet.
4. I personally had very bad experience with intuitive eating. It was working perfectly when everything was perfect, but when I had intense back pain for 6 months and couldn’t be as active as I used to and had a depression, 10 principle of intuitive eating just made everything only worse. I became to gain weight and with gaining weight my hunger start to become worse and worse and worse, and my weight start increase even more drastically, even though I didn’t restrict myself and followed these “miracle” 10 principles. I wasn’t even obese, just overweight, but it worsened my low back pain and I became more and more depressed, I developed knee pain (I have flat feet) and I even started to develop food anxiety and anorexic tendencies (I had never had such experience before) And you know what saved me? Calorie tracking, weighing myself and calorie restriction (moderate and balanced, obviously), that are SO demonized by modern “dietitians”. When you’re doing them right and treat data just like data, don’t act infantil, they don’t cause eating disorder, they actually helped me with it (suprisingly). I’m so happy that I said screw to IE and HAES (yeah, I was the one who was standing up for it) cause otherwise I would ended up morbidly obese and with bunch of mental issues.
P. S. Sorry, unpopular opinion among healthcare pros, I know.
HAES is well-known among the obese community for actively being pro-obesity. You should see how they treat obese people who have the temerity to actually lose weight.
You (along with many, many others) seem to have bought into the propaganda about how all it does is promote healthy body esteem. You obviously haven’t been paying attention to the movement over the past decade or you’d be more skeptical than you are.
Read more. Maybe look into the criticism a little deeper. It’s not all sunshine and roses.
Thank you for the comment Rick. I agree that sometimes there can be extreme views that prevent meaningful discussion. However, I don’t think one would deny that its emphasis on body acceptance, active movement, and flexible food choices are not beneficial elements. I’ve published quite a few studies on these principles, and it’s generally known that their associated with many different positive health outcomes.