About Health at Every Size® (HAES®)
The conversations and ideas that served as the foundation for what would become Health at Every Size® date back to the civil rights movement of the 1960’s. Through the many varied conversations about the oppression fat people face in healthcare and in the name of health emerged groups of (mostly) professionals discussing an alternative approach to providing healthcare to fat people that didn’t focus on weight loss.
In the late 1990’s this approach was named ‘Health at Every Size.’ In 2003, when ASDAH formed, the first version of the Health at Every Size® Principles was created based on existing related frameworks. The principles were revised in 2013 and again most recently in 2024. The Health at Every Size® Framework of Care was created in 2024.
The Health at Every Size® Principles serve as the guideposts for our work. They are the enduring beliefs underlying our work, even as the world changes, as science evolves and new information emerges. The Health at Every Size® Framework of Care serves as a roadmap for providers to become HAES®-aligned. Health at Every Size® Providers work to include all elements of the Framework of Care into their learning and practice. Health at Every Size® is an ever-evolving model and HAES®-aligned Providers are committed to the continuous learning to stay up-to-date.
Health at Every Size® Principles
Healthcare is a human right for people of all sizes, including those at the highest end of the size spectrum.
People of all sizes, including those at the largest end of the size spectrum, have the right to healthcare without exception. Fat people’s access to compassionate & comprehensive healthcare should not depend on obtaining a certain BMI, pursuing weight loss, and/or holding health as a value or pursuit.
Wellbeing, care, and healing are resources that are both collective and deeply personal.
Because health exists on a continuum that varies with time and circumstance for each individual, Health at Every Size® aims to focus on wellbeing, care, and healing. These are resources from which we can all pull to meet our needs. And we get to have others pour those resources into us and vice versa. Community care and mutual aid is key. Health at Every Size® providers and advocates must work to promote and create the conditions that support wellbeing i.e. environmental care, clear air & water, equitable access to food, and more. Each person is the expert of their own body and should have the right to make autonomous decisions about their health and wellbeing, including how they value or prioritize health among all the other important aspects that make up a life.
Care is fully provided only when free from anti-fat bias and offered with people of all sizes in mind.
Anti-fat bias, and fatphobia are detrimental to the health and wellbeing of all people, especially fat people. When health research, health policy, health education, and the provision of care does not include the full human size spectrum, it harms people of all sizes and is the antithesis to Health at Every Size®. Those who provide Health at Every Size®-aligned care must strive to dismantle anti-fat bias personally and systemically in order to provide care for all bodies.
Health is a sociopolitical construct that reflects the values of society.
How our society currently defines health is rooted in white supremacy, anti-Black racism, ableism, and healthism. As the values of our society become more rooted in collective liberation, we have the opportunity to critically examine and redefine health, disease, and illness. Regardless of the definition of health, however, access to care must never depend on an individual’s or community’s health status, pursuit of health, or compliance with health recommendations.
Health at Every Size® Framework of Care
The Heath at Every Size® Framework of Care was developed from 2022-2024 to serve as a roadmap for Healthcare Providers to become Health at Every Size®-aligned. These core elements are equally necessary in the provision of Health at Every Size®-aligned care, and while they are numbered for ease of referencing each item, there is no hierarchy. They can be thought of as trusses of a bridge, each one vital for the stability of the framework. Without any one of these, Health at Every Size®-aligned care is not possible. None of these are static. Ongoing learning is required to stay up-to-date and continuously improve HAES®-aligned care.
1. Grounding in liberatory frameworks
Health at Every Size® is not a liberatory framework or social justice movement in and of itself, but rather aims to align with other movements in order to further the journey towards liberation for all. We remain committed to the ongoing learning from liberation thought-leaders in Black liberation, fat liberation, crip/disability justice, queer liberation, womanism, intersectional feminism, and many more known and not-yet-known movements working towards the liberation of all people. Without this commitment, our work risks contributing to the oppression of the most marginalized in the pursuit of a false sense of liberation for the few.
3. Informed Consent
Patients have the right to informed consent. This concept is also common in the current healthcare system, but is not practiced through the lens of liberation for all. Informed consent must include what we don’t know just as much as what we do know. For example, researchers often exclude people in certain BMI ranges from studies on treatment effectiveness, leading to gaps in our medical knowledge. Fatphobic and healthist ideas influence what we believe is the best course of treatment, or even whether or not providers share certain information. Instead, informed consent must be provided without bias and with a focus on patient autonomy.
6. Skills and equipment to provide compassionate and comprehensive care for fat people’s bodies
Developing empathy for others is only one part of providing compassionate care. Providers must also develop the skills to provide care in compassionate and comprehensive ways and provide equipment designed for the full range of fat bodies. From learning appropriate ways to handle asking for a weight to physical exams on larger bodies to skills for administering various treatments on larger bodies, providers must learn what is necessary for Health at Every Size®-aligned care that their training did not cover.
7. Provider Roles and Responsibilities
Health at Every Size®-aligned providers apply ethical and liberatory frameworks to understanding their roles and responsibilities when providing care. This is especially important when the current medical system is set up so that providers hold the keys to accessing many forms of care. Additionally, Health at Every Size®-aligned providers have an ethical framework to guide them in understanding how they will support patients in ways that support harm reduction in a weight biased world.
9. Addressing Your Anti-Fat Bias
Providers must examine their internalized and externalized biases related to weight, including fat providers. Everyone holds biases, and addressing our beliefs, attitudes, and practices that may be rooted in bias is critical for making space for a Health at Every Size®-aligned practice.
2. Patient Bodily Autonomy
While this concept is more readily applied in healthcare settings as a patient’s right to refuse medical procedures, it is less commonly applied to a patient’s right to choose how they proceed with a treatment plan after being provided with all options and informed of known (and unknown) risks and benefits. Most restrictions based on BMI and the pervasive practice of refusing care until some other criteria is met (e.g. weight loss, trying ‘lifestyle’ intervention first, trying a certain treatment before considering other options, etc.) are violations of patient autonomy in most cases. Health at Every Size®-aligned providers honor patient autonomy in the broadest possible way when ethical to do so.
4. Compassionate Care
Compassionate care for our patients is about developing empathy (not pity) for the huge range of life experiences that influences an individual’s health status and their relationship to health and the healthcare system. Health at Every Size®-aligned providers seek out stories different from our own to broaden our understanding of the world and the diversity of experiences it contains so that care is provided through the ever-expanding lens of compassion for our patients.
5. Critical analysis, application, and execution of research & medical recommendations related to weight
Anti-fat bias has played a profound role in shaping the medical research and recommendations widely used in today’s healthcare system. One of the main roots of the current Health at Every Size® community was a group of fat activists known collectively as the Fat Underground who began questioning their healthcare experiences and the advice they received from healthcare professionals. They discovered the research on health and weight was not aligned with the recommendations from their healthcare professionals.
The issues they brought to light persist today, and in many cases have worsened. Providers must consider the way weight bias has influenced the research design and interpretation of studies underlying their training, clinical recommendations, and policy that impacts fat people.
8. Tools that support wellbeing and healing without contributing to oppression
Health at Every Size®-aligned providers are equipped with tools that support patient health goals without the pursuit of weight loss. This includes relearning tools co-opted by the weight loss industry like nutrition and physical activity, as well as learning the tools to help our patients reframe their relationship with food and movement in alignment with their values. Health at Every Size®-aligned providers learn about and offer treatments for various health conditions that don’t rely on weight loss.
10. Addressing Systemic Anti-Fat Bias
Health at Every Size® Providers are committed to the ongoing work of addressing systemic anti-fat bias. From our colleagues to workplace and government policy, we must be committed to abolishing the BMI, dismantling the Medical Industrial Complex, and creating the conditions for care of all people to be fully realized.
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A Brief Introduction to Health at Every Size®
First and foremost that health care must be accessible to people no matter their size, and no matter why they are any given size. This disproportionately affects fat people because our current societal norms prioritizes and normalizes slender and thin bodies. Anti-fat bias has created an environment where even in health care (where we expect people of all ability levels and health statuses to be included) equipment, gowns, and seating is not designed for all bodies.1 Additionally, health care providers commonly hold anti-fat bias and fatphobic beliefs. Most providers believe that fat people become fat through neglect of their health, that fat people are lazy, and that fat people are non-compliant with health recommendations.1,2 These beliefs lead to significant health care avoidance by fat people and they lead to poorer quality care when we do seek out health care.
An area of research that has profoundly influenced the development of the Health at Every Size® Principles is the effectiveness of intentional weight loss efforts. Efforts to make fat people thin fail over and over.3 And in fact we have decades of research on diets and “lifestyle changes” that show that, while people can intentionally lose weight for 6 months to one year, they eventually regain most, all, or even more than they initially lost.3
What’s worse is this thin-centric healthcare is not benign. It causes harm. One study showed fat women who intentionally lost at least 15% of their body weight were over two times higher risk of death compared to fat women who remained weight stable.4 Another study found that risk of dying from cardiovascular disease was higher in people who lost weight. That risk increased with more weight lost and the group that lost over 22 pounds was at 3.5 times higher risk of dying from cardiovascular disease compared to the weight stable group.5
Yet, many healthcare providers encourage weight loss for all fat patients despite this evidence. Some healthcare providers refuse to offer care like medication, referrals to physical therapy, and even deny surgery unless patients pursue and attain weight loss. This unethical approach to healthcare may account for all of the health disparities seen in fat people, and body size may not have any direct effect on health.
One of the most important aspects of the Health at Every Size® Framework of Care is that one of, if not the, most important ways to improve health is by eliminating oppression. Fatphobia and anti-fat bias are intimately connected to all other forms of oppression, especially racism. The focus on weight and weight loss disproportionately impacts the health of fat Black people.6 Many people might be surprised to learn that roots of our current society’s anti-fat attitudes is from early racist rhetoric in the 1700s and 1800s.7 So while we’ve abolished slavery and have laws about discriminating against people based on race, policies can (and do) still discriminate against fat people. This has become a way to continue the oppression of Black people.
Discrimination based on weight and size is incredibly prevalent in our current society. Fat people are less likely to be hired, more likely to be fired even when performance is good, and less likely to be promoted.2 Weight-based bullying is currently the most prevalent form of bullying in schools, fat students are less likely to be perceived as intelligent and hard working, and fat students are less likely to be admitted to higher education institutions.2 Entertainment venues, restaurants, airplanes and more are not designed with fat people mind. All of these areas of discrimination not only impact health through greater social isolation and creating additional barriers to healthcare through lack of insurance and less pay, they add to the overall stress of being oppressed (allostatic load) and contribute to poorer health and worse health outcomes.1,8,9
Another area of research that underlies the Health at Every Size® Framework of Care is the evidence that for fat people who choose to pursue health-promoting behaviors, health improvement is possible without a focus on weight or weight loss. One study compared risk of death by a number of healthy habits and by BMI. They found people who engaged in 2, 3, or 4 of the healthy habits had no significant difference in risk of death regardless of BMI status. So engaging in healthy habits has a greater effect on health than BMI.10
The Health At Every Size® Principles and Framework of Care seek to address the weight bias fat people face when seeking healthcare. In addition to what we’ve covered already, informed consent and body autonomy are two key concepts in providing HAES®-aligned care. The first, informed consent, is an approach to patient care that is trauma informed and supports the ethical provision of healthcare. Informed consent has two components, the first is consent, in which any procedure involving a patient requires their consent. The informed component highlights that consent cannot be given without a full understanding of the risks, possible outcomes, and what all is involved. Weight loss recommendations and requirements are almost never given with informed consent. We provide education and resources to providers and patients on this to help eliminate weight bias, discrimination, and fatphobia in healthcare.
References
- Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev. 2015;16(4):319-326. doi: 10.1111/obr.12266.
- Puhl RM, Heuer CA. The stigma of obesity: A review and update. Obesity (Silver Spring). 2009;17(5):941-964. doi: 10.1038/oby.2008.636.
- Mann, Traci, Tomiyama, A. Janet, Westling, Erika, Lew, Ann-Marie, Samuels, Barbra, & Chatman, Jason. (2007). Medicare’s Search for Effective Obesity Treatments: Diets Are Not the Answer. American Psychologist, 62(3), 220-233.
- D D Ingram, & M E Mussolino. (2011). Weight loss from maximum body weight and mortality: The Third National Health and Nutrition Examination Survey Linked Mortality File. Ožirenie I Metabolizm, 8(1), Ožirenie i Metabolizm, 01 March 2011, Vol.8(1).
- Park SY, Wilkens LR, Maskarinec G, Haiman CA, Kolonel LN, Marchand LL. Weight change in older adults and mortality: the Multiethnic Cohort Study. Int J Obes (Lond). 2018;42(2):205-212. doi:10.1038/ijo.2017.188
- Harrison DL. Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness. North Atlantic Books: 2021.
- Strings S. Fearing the Black Body: The Racial Origins of Fat Phobia. NYU Press: 2019.
- Vadiveloo M, Mattei J. Perceived Weight Discrimination and 10-Year Risk of Allostatic Load Among US Adults. Ann Behav Med. 2017 Feb;51(1):94-104. doi: 10.1007/s12160-016-9831-7
- Sutin AR, Stephan Y, Terracciano A. Weight Discrimination and Risk of Mortality. Psychol Sci. 2015;26(11):1803-1811. doi:10.1177/0956797615601103.
- Matheson, E. M., King, D. E., & Everett, C. J. (2012). Healthy lifestyle habits and mortality in overweight and obese individuals. Journal of the American Board of Family Medicine, 25(1), 9-15.
Debunking Myths about Health at Every Size®
Myth: Health at Every Size® means all fat people are healthy.
There are “healthy” and “unhealthy” people at all points on the size spectrum. The Health at Every Size® Principles promote safe and equitable access to healthcare for people regardless of size, health status, and health goals first and foremost. ASDAH also provides a Framework of Care for both providers to approach healthcare without a focus on weight or weight loss.
Myth: fat people deserve access to healthcare and are just generally worthy because they are healthy or have the capacity to be healthy.
Even if every single fat person was inherently unhealthy they would still have inherent worth and deserve access to quality healthcare, full stop.
Myth: Health at Every Size® is about convincing all fat people to pursue health or attain a ‘healthy’ status.
We are first and foremost about increasing access to quality healthcare for fat people. We also offer a Framework of Care that includes tools for providers and patients to approach health from a lens of fat liberation. It is imperative that fat people have access to care regardless of if they pursue health or attain a ‘healthy’ status.
Myth: Health at Every Size® is a social justice movement.
Health at Every Size® is an orientation to health and healthcare that encompasses many approaches & practices. We aim to ground our principles, framework of care, education, and advocacy in liberatory frameworks that are congruent with social justice.
A Brief History of the Health at Every Size® Principles
When ASDAH first formed in 2003, the original steering committee (Claudia Clark, Miriam Berg, Roki Abakoui, Donna Pitman, Paul Ernsberger, Catherine Shufelt, Veronica Cook-Euell, Judy Miller, Lisa Breisch, Francie Astrom, Renee Schultz, Darshana Pandya, Judy Borcherdt, Joanne Ikeda, Ellen Shuman, Dana Schuster) agreed that the work of the organization would be based on a set of Health At Every Size® Principles. Most of the versions of the Health At Every Size® Principles in use at the time incorporated aspects of tenets previously put forth by Joanne Ikeda, Karen Kratina, Francie Berg, and/or Deb Burgard. Some listed both the basic beliefs that were consistent with a Health at Every Size® model and those that were not acceptable under a Health at Every Size® model, while all included reference to: acknowledging size acceptance and diversity; pursuing an aware/intuitive approach to eating; engaging in individualized and enjoyable physical activity; and recognizing/appreciating health as being multi-faceted. Based on these shared understandings, the steering committee crafted and adopted the five original Health At Every Size® Principles that have appeared on ASDAH materials and the website from 2003 through 2013.
It gradually became clear leading up to 2013 that ASDAH’s original Health at Every Size® principles did not fully reflect the evolving political and sociocultural milieu or the growing consensus regarding the social determinants of health. The revised set of principles acknowledged social justice and access concerns while retaining the original intent and wisdom of the Health At Every Size® principles as they had been practiced for many years. The team leading the 2013 revision included Dana Schuster, Shelley Bond, Kathy Kater, Judith Matz, Christine Ohlinger, and Amy Herskowitz.
After much community conversation, the Health at Every Size® Principles were revised again from 2022-2023 for the third and current version. The revisions focused on clarifying what was a principle (a fundamental truth that serves as the foundation for a chain of reasoning) and what was missing from the principles to more fully align with our liberatory values. ASDAH leaders ani janzen, Angel Austin, Veronica Garnett, Da’Shaun Harrison, and Pontsho Pilane led the revision through multiple rounds of community input via surveys and focus groups.