By Sarabeth Lowe, MPH

Ms. Lowe is a Communication Specialist at the University of Delaware Disaster Research Center.

America has been hooked on dieting for more than 100 years.¹ Its legacy is evident across our culture. The media has long-depicted slender bodies as the ideal shape and size. Influencers peddle appetite suppressants and other alternative weight-loss products with little or no evidence, fanning the flames of misinformation. In 2023, the total United States (US) weight loss market was estimated to have grown to a historic peak of $90 billion.² All of this reflects the staggering scale of this industry and the extent to which diet culture is entrenched in our ethos. It has also reinforced weight-based discrimination as the status quo.^3–5

At the same time, rising rates of obesity have become a target for public health action. As experts evaluate existing frameworks for obesity management and prevention, a truth has emerged: conventional strategies, many of them based strictly on weight reduction, aren’t working.^6–9 Alternative approaches have come to the forefront, and Health at Every Size® (HAES) has drawn both inspiration and ire from experts, as it challenges the commonly held belief that a lower weight is synonymous with better health.⁹ There’s more nuance to this approach than its name suggests, though. Here’s what you need to know.

What is Health at Every Size®?

HAES® is a lifestyle counseling approach that does not focus on any measure of body weight, size, or shape.^6,10–12 This paradigm offers an alternative to weight-centered definitions of health and encourages health-promoting behaviors, regardless of their impact on body weight. It promotes body acceptance and intuitive eating and supports physical activity and movement for health purposes rather than elite performance or changing the shape of your body.^6,11,13,14 Notably, this approach does not claim that everyone is healthy, no matter their size. Rather, it rejects body weight or size as proxies for health.¹² 

While the HAES® framework is relatively new, its beginnings date back to the civil rights movement of the 1960s.¹⁰ More specifically, its roots begin with the “fat acceptance” movement, which was entwined with other social justice movements fighting forms of oppression, including racism and sexism, at the time.¹⁵ A group of advocates, most of them medical professionals, that would eventually evolve into the Association for Size Diversity and Health (ASDH) emerged from this movement. Through the many varied conversations about the challenges that overweight people face when accessing healthcare, the ASDH created the HAES® framework in the 1990s.¹⁵ In 2003, the organization established the earliest versions of its key principles that would underlie and guide its work.¹⁰ These principles were thoughtfully revised with community input in 2024 and are as follows:¹⁰

1. Healthcare is a human right for people of all sizes, including those at the highest end of the size spectrum.
2. Wellbeing, care, and healing are resources that are both collective and deeply personal.
3. Care is fully provided only when free from bias against overweight individuals and offered with people of all sizes in mind.
4. Health is a sociopolitical construct that reflects the values of society.

In a nutshell, the goals of HAES® are to define health in a more inclusive way, improve access to bias-free healthcare for bodies of all sizes, and challenge weight discrimination.¹² Despite this being a compassionate and effective approach to patient care, there are many misconceptions about this framework. The pushback against HAES® is heated and can be polarizing.^8,16,17 Some of this resistance might be because it’s such a radical departure from the typical weight-centric view of health, which often hinges on a narrowly defined and socially constructed body size.^6,12 Still, there are concerns about how, or if, this approach can improve public health, with compelling arguments on both sides.^18,19

A Need for More Empirical Evidence 

Researchers have conducted thousands of studies comparing HAES® to weight-centric approaches and their effects on improving health, but drawing absolute conclusions from their results is difficult.^6,19,20 Many existing studies have small sample sizes with relatively little diversity, limited evaluation of certain specific health outcomes, and a tendency to treat obesity by focusing on individual characteristics while excluding important omnipresent environmental influences.

Additionally, studies testing HAES® interventions have shown conflicting results. For example, some researchers have observed positive impacts on psychological wellbeing and eating behaviors, while others report no significant changes in physical or mental health outcomes or metabolic markers.^6,11,21 There have also been mixed findings on the long- and short-term impacts of HAES® strategies. This indicates that the effectiveness of HAES® approaches may depend on individual factors and study design.⁶ Furthermore, while replicating results is not necessarily a sign of a poorly designed or flawed study, it does build confidence in the scientific merit of a study’s findings.²² 

These limitations and lack of empirical data make scaling and implementing HAES® interventions difficult.^6,20 Given this, experts say researchers studying these approaches should be cautious about generalizing their findings.⁶ The viability and efficacy of HAES® as a public health intervention are still hotly debated topics among experts, but most can agree on one sentiment: the choice about whether to use this approach will depend on a person’s preferences, goals, and needs.^{6,9,11,16,17,21}

Bottom Line

While the HAES® framework has limits as a public health intervention, that certainly does not mean it is without merit. A growing body of research shows that it is an evidence-based, compassionate, and effective model for patient care.^16,17 As more organizations and experts recognize and acknowledge the naturally existing diversity in body sizes and the ineffectiveness and harm of weight-centric approaches, an increasing number of dietitians and health professionals are implementing HAES® practices in their work.^8,9,23–26

Like all health improvement strategies, HAES® is not a one-size-fits-all solution. Its potential to inform policy and improve wellbeing, however, should inspire innovation instead of ire. Rather than digging their heels into an already polarized debate, public health practitioners and medical professionals should find common ground and move toward a new paradigm that honors and supports the right to quality and bias-free healthcare for all people, no matter their body size.

Sources

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