About Health at Every Size® (HAES)
The Association for Size Diversity and Health (ASDAH) affirms a holistic definition of health, which cannot be characterized as the absence of physical or mental illness, limitation, or disease. Rather, health exists on a continuum that varies with time and circumstance for each individual. Health should be conceived as a resource or capacity available to all regardless of health condition or ability level, and not as an outcome or objective of living. Pursuing health is neither a moral imperative nor an individual obligation, and health status should never be used to judge, oppress, or determine the value of an individual.
Centering this definition of health, the Health At Every Size® (HAES) Principles and framework are a continuously evolving alternative to the weight-centered approach to treating clients and patients of all sizes. The Health At Every Size® Principles promote health equity, support ending weight discrimination, and improve access to quality healthcare regardless of size.
The current version of the Health At Every Size® Principles were last updated in 2013. Our organization and community discussions around what Health at Every Size® means have evolved immensely and the current principles do not reflect much of the evolution. Our top priority during the 2022-23 board year will be updating the principles.
Health at Every Size® Principles
Accept and respect the inherent diversity of body shapes and sizes and reject the idealizing or pathologizing of specific weights.
Support health policies that improve and equalize access to information and services, and personal practices that improve human well-being, including attention to individual physical, economic, social, spiritual, emotional and other needs.
EATING FOR WELL-BEING
Promote flexible, individualized eating based on hunger, satiety, nutritional needs, and pleasure, rather than any externally regulated eating plan focused on weight control.
Acknowledge our biases, and work to end weight discrimination, weight stigma, and weight bias. 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.
Support physical activities that allow people of all sizes, abilities, and interests to engage in enjoyable movement, to the degree that they choose.
Unpacking the Health at Every Size® Principles
Weight inclusivity means 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 primarily affects fat people because our current societal norms prioritizes and normalizes slender and thin bodies. Fatphobia has created an environment where even in health care, where we expect people of all ability levels and health statuses should be included, equipment, gowns, and seating is not designed for all bodies.1 Additionally, health care providers commonly hold 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 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.
Health Enhancement covers a huge range of topics from health equity to the social determinants of health to community care to individual approaches to health. One of the most important aspects of this principle is that one of, if not the, most important ways to improve health is by eliminating oppression. Fatphobia and weight 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 fatphobia 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, policy discriminating against fat people 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 supports this principle of Health at Every Size® 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.
The Health At Every Size® Principle Respectful Care seeks 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 included in this principle. 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.
Lastly, the principles of Life-Enhancing Movement and Eating for Wellbeing are likely to be removed as principles and instead be included as tools. These are approaches to health that are congruent with the Health at Every Size® framework. However, because many people do not have access to or do not prioritize these aspects of wellbeing, they don’t fit as a core principle of Health at Every Size®. Health at Every Size® should work for all people, regardless of their health goals.
- 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.
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. The Health at Every Size® Principles also provide a framework of care for both providers and individuals to approach health 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. Periodt.
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 for care to help providers and patients think about health from a lens of fat liberation. Neither of these require fat people to pursue health or attain a ‘healthy’ status.
Myth: Health at Every Size® is a social justice movement.
Health at Every Size® is a framework for care. We aim to ground the principles, curriculum, 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.
It has once again become clear that a revision is necessary. The current principles do not adequately support those most impacted by medical fatphobia nor do they reflect ongoing reflection and community discussion. ASDAH Leadership plans to revise the Health at Every Size® Principles during the 2022-23 board year.