When people hear me use the term, “HAES” when describing my approach and philosophy as a registered dietitian, the acronym is often unfamiliar to them. I wanted to take the opportunity to address this in more detail with a discussion about the HAES® movement and what it means to be a HAES dietitian.
The acronym HAES® stands for Health At Every Size, a movement coined by the Association for Size Diversity and Health (ASDAH) in 2003. Lindo (formerly Linda) Bacon, PhD, author and researcher further popularized the movement in 2008 with the publication of their book, “Health at Every Size: The Surprising Truth About Your Weight.” Since then, numerous doctors, dietitians, physical therapists, nurse practitioners, nurses and other clinicians have embraced the movement and transformed the way they practice to better support the individuals they work with.
What is Health at Every Size?
At its core, the HAES® movement seeks to inform the public that weight, Body Mass Index (BMI) and body size are not adequate measures of health status. Health is much more complicated than a number on the scale and as a culture, our extreme focus on weight is actually causing more harm than good. The HAES model acknowledges that correlations between weight and health problems do exist, however, there is more evidence suggesting that the role of factors separate from weight have a stronger pull in terms of their influence on health status.
Tylka and colleagues argue that the weight normative model of today’s healthcare system is counterintuitive to the ethical principles of healthcare providers who have a responsibility to do no harm to patients and communities. Furthermore, the authors explain, “the dominant focus on weight loss and weight management may move health care professionals away from these principles, creating a dilemma in the delivery of ethical care and public health promotion. The dilemma occurs because a weight-normative approach to health emphasizes the pursuit of weight loss, despite extensive evidence demonstrating that weight loss is not sustainable long-term for most people and weight cycling (commonly associated with weight loss efforts) is linked to adverse health.”
The mission of ASDAH is to use the HAES message to influence both public health policy AND healthcare practice.
Below you’ll find the 5 principles of HAES, taken directly from the ASDAH website.
- Weight Inclusivity: Accept and respect the inherent diversity of body shapes and sizes and reject the idealizing or pathologizing of specific weights.
- Health Enhancement: 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.
- Respectful Care: Acknowledge our biases, and work to end weight discrimination, weight stigma, and weight bias. Provide information and services from an understanding that socioeconomic status, race, gender, sexual orientation, age, and other identities impact weight stigma, and support environments that address these inequities.
- 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.
- Life-Enhancing Movement: Support physical activities that allow people of all sizes, abilities, and interests to engage in enjoyable movement, to the degree that they choose.
The Evidence Supporting HAES
While the movement definitely receives its share of criticism due to the weight centric ideals held by many in the health and wellness industry, there is evidence based research to support Health at Every Size. I’ll highlight some research findings below that demonstrate the efficacy of moving away from a weight normative model.
*Please note I use the terminology “obese/obesity” in the research summaries as this is the language used in medical literature. I prefer not to use those terms in my daily language and conversations as I find them to be stigmatizing.
- In a Meta Analysis of 29 studies, researchers examined the sustained weight loss of individuals who participated in very low calorie diet weight loss programs. At the 5 year mark, participants had regained 77% of the initial weight loss, maintaining an average weight loss of 3 kg.
- Weight stigma can be defined as the negative weight related beliefs held by individuals that lead to prejudice, stereotypes and discrimination of people who live in larger bodies. Often these people are subject to bullying, harassment and immense pressure to lose weight.
- Stigmatizing and fat shaming people in higher weight bodies does not motivate behavior change. In fact, research shows it does the opposite: one study demonstrated higher calorie intake in those experiencing weight stigma.
- Additional studies discussed in this 2014 review show evidence that weight stigma was related to increased blood pressure, unhealthy weight control behaviors, binge eating, depression and low self-esteem.
- Weight cycling (repeated cycles of weight loss, followed by weight regain) is shown in multiple studies to be associated with adverse physical and psychological outcomes.
- Using data from the Nurses Health Study II, researchers found women with a history of weight cycling, gained more weight overtime, participated in less physical activity and experienced more binge eating vs their peers without a history of weight cycling.
- A 2012 study that examined data from NHANES III (National Health and Nutrition Examination Survey) looked at the association of healthy lifestyle behaviors (regular exercise, eating ≥ 5 servings of fruits and vegetables daily, not smoking and moderate alcohol intake) and mortality of roughly 12,000 men and women above age 21 across all BMI categories. They concluded that healthful habits are associated with significantly decreased mortality regardless of BMI, with the greatest benefit seen among individuals in the obese BMI category.
- In this randomized controlled trial, obese women were assigned to a traditional dieting group or a HAES intervention for 6 months and then followed for 2 years. Dropout rate was 41% among the traditional diet group vs 8% in the HAES group. At 2 year follow up, the HAES group maintained baseline body weights and had sustained improvements in metabolic (lipid profile, blood pressure) and psychological (self esteem and depression) outcome measures. The dieting group lost weight initially and had improvements with the above outcomes measures, but regained the weight at 2 year follow up with little sustained improvement in other outcomes measures.
HAES in action
Now that you have a basic understanding of the HAES model, I’ll demonstrate examples of how a HAES dietitian implements these principles into everyday practice with patients and clients.
We advocate for a weight inclusive approach not only in the dietetics profession, but in all healthcare settings. Research shows us that in the current weight normative model, biases exist among professionals that prevent patients in larger bodies from seeking medical care due to fear of discrimination based on weight. Avoidance of medical care due to these fears helps explain why the prevalence of certain chronic medical conditions is higher among individuals living in a large body. Eschewing healthcare translates to lack of appropriate screenings and/or diagnostic tests, medical interventions and treatments to prevent, manage or delay onset of disease.
We challenge the belief that body weight is within our control so long as we manage “calories in and calories” out. This simply isn’t the case, weight regulation is much more complex. Genetics, socioeconomic status, environment and many other factors influence a person’s body weight. It’s important to understand that health exists among a wide spectrum of weights and body sizes.
A HAES dietitian doesn’t support the pursuit of weight loss as a way to improve health status, rather they focus on other health enhancing behaviors that consider an individual’s values, beliefs, food preferences, abilities, barriers and financial means. We discourage the pursuit of weight loss because the majority of people who attempt weight loss through calorie restricted diets will regain the weight and often fall into a harmful pattern of weight cycling. The same people are then led to believe that “they failed,” when in reality, it was the diet that failed them. Dieters aren’t fighting against their “willpower,” they’re fighting their biology, and news flash: biology almost ALWAYS wins.
Counterintuitive to what the general public may believe about dietitians, we understand that there is more to health than just food. Health is multidimensional and requires a holistic approach that considers how a person’s economic, physical, social, spiritual and emotional status contributes to overall well being.
A HAES dietitian meets patients where they are to provide support and treatment that accounts for the aforementioned needs. Furthermore, the clinician seeks to understand the “whole” person by recognizing their unique situation, allowing for individualized nutrition support.
In order to provide respectful care to people living in all body sizes, we must address our own biases around weight. Asking yourself what beliefs you hold about individuals of higher weights vs what you believe about thin people can help this process. We are led to believe that if someone is living in a higher weight body they are lazy, don’t care, eat only “junk” food and more. On the contrary, we may view someone in a thin body as “good” or disciplined or think they only eat “healthy” food. In other words, society has a tendency to assign morality to body size, where thin = good or superior and fat = bad or inferior. The common habit of assigning morality to body size perpetuates weight stigma.
To practice nutrition and dietetics through a HAES lens, one must address these false beliefs. These common perceptions result in oppression of people in large bodies, which is shown to contribute to negative health outcomes. Respectful care becomes possible when we stop making assumptions about a person’s behaviors and eating habits based on their appearance. Dietitians who have addressed these concerns are able to provide compassionate care and treat individuals from all walks of life with dignity and respect.
Eating for Wellbeing:
Many dietitians who embrace the HAES philosophy also utilize the principles of Intuitive Eating (IE) in their work. In short, IE is a framework that helps individuals tune into the body’s internal wisdom vs listening to external messages (diets, protocols, etc) about what one “should” be eating. Through the process of IE, dietitians help clients dismantle the beliefs diet culture has ingrained in our heads about food, nutrition and health.
Evelyn Tribole and Elyse Resch, dietitians and co-authors of the book “Intuitive Eating,” often refer to satisfaction as the “Hub” of Intuitive Eating. HAES practitioners support clients in discovering satisfaction with food and eating, while overcoming shame and guilt around food choices. We don’t believe in assigning “good” or “bad” labels to food and hold the belief that food is neutral. Over time, clients are guided on how to honor their health with gentle nutrition recommendations.
Life Enhancing Movement:
We support forms of movement that offer pleasure and enjoyment vs strict regimens that punish, shame or cause injury. We discourage using physical activity as an indicator of whether or not someone has “earned” the right to eat dessert or any food for that matter. Using exercise as a means to compensate for food intake is a disordered behavior.
When aesthetics or weight loss is the motivation behind exercise and physical activity, the sustainability of the activity is short-lived. HAES dietitians encourage clients to explore activities within their level of ability to determine what they enjoy and what feels best for their body. Life enhancing movement boosts mood, improves flexibility and joint health and also decreases risk for many chronic diseases.
I asked some fellow Registered Dietitians what it means to to align with the HAES framework, here’s what they had to say:
Practicing as a Health At Every Size® Expert has been a total career-changer for me. Not only has it made me more aware of inequities in the healthcare system that I can help my clients navigate, it also allows me to create relationships with my clients in which I am an ally rather than an adversary. Further, I find that I no longer feel the need to convince anyone of my credentials in this field – bodies are the experts, and HAES speaks for itself and it does not apart under scrutiny.Jamie M. Marchetti, MS, RDN, LD
Our diet-based culture tends to pull us out of our here-and-now lives. It teaches us to constantly strive for who we think we were in the past, or who we think we should be in the future. Taking a HAES approach reconnects my clients to the present moment in a more mindful, aligned way, and allows them to tap back into their joy and life passions.Jessica Serdikoff, RDN
Becoming a HAES-informed dietitian truly transformed the work that I do. It allows the space and ability to connect on a deeper level — to say, “I see you (the whole you). I’m here to listen with compassion first, rather than fix.” Likewise, at the end of the day, I find most people are looking for the principles. For example, somewhere all along, “eating for well-being” and “life-enhancing movement” makes sense, rather than the idea of food vs. movement battling one another. There is more flexibility for conversations around sleep, community, stress-reduction and stress-management, as well as access to care.Ashley Homrich, RD, LDN
Want to learn more?
I recommend the books below to get started on your journey:
Looking for a HAES dietitian near you?
Check out the following directories to locate a provider in your area. If you’re looking to work with someone virtually, I provide coaching services through a HIPAA compliant video platform.
I truly hope you learned something new by reading this article. Perhaps it sparked an interest to learn more about this movement or even gave you some points to ponder about the compassionate healthcare treatment you deserve. Share your thoughts with me below!
Claire Carlton, MS, RD, LDN