Health at Every Size (HAES) for People with Diabetes
Introduction
Weight reduction has long been a central recommendation for larger-bodied people with diabetes. However, the RACP1 and RACGP2 have recently recommended that health professionals shift to a ‘health gain’ rather than ‘weight loss’ approach for people with a body mass index (BMI) greater than 30kg/m2. Both organisations justify this change of approach on the basis that behavioural weight-centric approaches are rarely successful in the long-term (3-5 years), entrench weight stigma and can be psychologically and physically harmful for some people.3 Health professionals making assumptions about the health intentions of someone on the basis of their body weight, the controllability of body weight, or lifestyle behaviours because of their weight is a common cause of frustration and healthcare avoidance for larger-bodied health service users.4 The Health at Every Size (HAES) philosophical framework5 offers a healthcare model that supports healthcare providers and community members to meet ‘health gain’ aims without the pursuit of weight loss.
What is Health at Every Size (HAES)?
Health at Every Size (HAES)® refers to a set of philosophical principles (Figure 1) determined by the Association for Size Diversity and Health (ASDAH) in the USA and is reaffirmed by HAES Australia in Australia. In the context of the principles, ‘health’ is used as a goal, value or pursuit, rather than a statement that everyone is ‘healthy’ regardless of size. These principles were developed by healthcare providers, anti-discrimination and anti-stigma activists, and people with lived experience of navigating healthcare services with a higher body mass in developed countries including the USA, Canada, UK, Australia and New Zealand.
| 1. Weight Inclusivity: Accept and respect the inherent diversity of body shapes and sizes and reject the idealizing or pathologizing of specific weights. 2. 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. 3. Respectful Care: 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. 4. Eating for Well-being: Promote flexible, individualised eating based on hunger, satiety, nutritional needs, and pleasure, rather than any externally regulated eating plan focused on weight control. 5. 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. |
Figure 1. Health at Every Size Principles (ASDAH)
For healthcare services, the HAES principles can form a guide for providing ethical, weight-inclusive care. That is, services that welcome and accommodate people of all sizes and abilities without triaging care on the basis of weight or BMI, and without using weight as a relevant outcome or adherence measure. For health professionals that work with individuals, HAES-based approaches offer clients an alternative suite of goals that may prioritise health-enhancing lifestyle habits, confident management and understanding of health conditions (and their direct biomarkers) and compassionate self-acceptance. For Diabetes Educators, the HAES principles offer a guide for supporting people with diabetes to regularly engage in enjoyable physical activity, eat well and manage their blood glucose levels (BGLs) without closely controlling energy intake.
Is HAES evidence-based?
The relationships between a health-focused, size-accepting attitude and health behaviours and outcomes have been explored in both observational and interventional research studies. At a population level, key behaviours such as eating five or more serves of fruit or vegetables on most days, being physically active, not smoking and not drinking alcohol beyond the levels recommended in public health guidelines does much to mitigate BMI-related factors on overall mortality. Large studies by Matheson et al6 and Khaw et al7 found that those four health behaviours, regardless of BMI category, related strongly to decreased mortality risk. Of course, the benefits of behavioural recommendations for people with diabetes who have a BMI in the range of 18.5-25kg/m2 such as cardiovascular fitness and strength,8 an eating pattern centred around a varied intake from each of the five food groups9 and optimal blood glucose management principles,10 also have positive effects on health outcomes for those with a higher BMI. In fact, higher BMI and physical fitness level were significantly related to lower mortality for people with diabetes in a recent observational study of 8528 American adults,11 calling into question the assumption that a BMI less than 25kg/m2 be deemed universally ‘healthy’ at the exclusion of other BMIs.
Intervention research where a HAES approach has been directly compared with a weight loss approach for larger-bodied people (particularly women with body image distress) have found that the HAES intervention participants were more likely to sustain health-supporting eating habits than those trying to lose weight.12 Six systematic reviews of interventions using HAES-informed approaches have been published to date,13-18 with all concluding that these interventions are also associated with positive psychological outcomes such as improved body image, self-esteem, self-worth, psychological functioning and decreased internalised weight stigma. Positive biomedical outcomes such as reductions in blood cholesterol levels and blood pressure were found to be similar for weight loss and HAES approach groups, despite no significant weight change in those assigned to the HAES-based interventions. Importantly, no evidence of negative psychological reactions to HAES approach interventions was detected although follow up is not currently available after the 3-5 year mark.
What kind of client might be suitable for a HAES approach?
From a philosophical standpoint, the HAES principles are for people of all shapes and sizes. However, in practice, it is visibly larger-bodied people who face both systemic and interpersonal weight discrimination and stigma in healthcare settings,4 making the potential for HAES principles to enhance care most pronounced in this group. In one experimental study, highly educated white women who were already engaged in some health behaviours were more likely to complete a HAES-informed intervention.19 In another, larger-bodied women with lower internalised weight stigma were more likely to fully engage in a HAES-based group program.20 Additionally, this approach may be attractive to people who have experienced repeated weight regains after intentional weight losses, those who experience distress about their body weight or shape and those who (for whatever reason) do not wish currently to pursue weight loss.
Example:
Susan, a middle-aged woman has just received a diagnosis of type 2 diabetes and has been referred to Jane, a CDE. Prior to her diagnosis, Susan had been dieting on and off for years and berates herself for not being able to get her weight ‘under control’. She recounts to Jane in their first appointment that deep down she blames her diabetes diagnosis on her higher body weight but is also mentally exhausted after having yo-yo dieted for the previous twenty years with no tangible results. When Jane first practiced as a CDE she used a weight-centric approach, but has since received further training and now offers her clients the choice of a weight-centric or weight-neutral approach. Jane explains that regardless of the factors that have led to changes in Susan’s blood glucose regulation, or her higher body weight, her recent diagnosis has offered an opportunity for Susan to take care of her body in a new way. She describes Susan’s options: learn about balancing a healthy lifestyle, blood glucose regulation and managing her condition with the best that current science can offer with negotiated health behaviour-related goals, either with a renewed focus on a weight loss goal (weight-centric approach) or combining the lifestyle goals with size acceptance (HAES approach). Susan is intrigued to hear about the HAES approach and decides to put weight matters on the backburner while trying to understand the day-to-day patterns and management of her BGLs. Together, Susan and Jane develop a lifestyle plan that includes food literacy and carbohydrate awareness, a health-supporting eating pattern that’s enjoyable and responsive to Susan’s appetite cues and BGLs, and regular physical activity. After six months, Susan is feeling more energetic, is sleeping well, has within-range HbA1c levels and feels much more positive and caring towards her body and lifestyle choices. Susan knows that she has the choice to return to a weight-centric approach at any time but is very happy to continue with the current plan for the time being.
Where can I learn more?
Theoretical information can be found on the ASDAH and HAES Australia websites and in many of the papers referenced in this article. Upskilling in the delivery of a HAES approach involves learning about internalised and externalised weight stigma and their impact on the therapeutic relationship as well as an appreciation of the outcomes of weight-neutral lifestyle interventions. There are now multiple HAES education providers and it is advisable to seek collegial and interprofessional support to develop your HAES approach skills, for example with mentoring or clinical supervision from an experienced HAES clinician. It is not easy to switch paradigms when both society and healthcare training has historically placed a lot of emphasis on weight control. Rochefort et al offer an example of this learning process in their account of moving into a HAES approach in the discipline of dietetics,21 where this approach has received much international and domestic research attention, recently being found to be well accepted and utilised by Accredited Practising Dietitians in Australia.22 If your client is interested in pursuing a HAES approach, ensure continuity of care by connecting them with HAES providers across the different disciplines they require (check the services offered within your referral network as HAES approach skills may vary between practitioners).
Conclusion
The HAES principles provide an evidence-based framework for the delivery of health-focused, size-accepting individualised care, community care and public health initiatives. Regardless of whether you choose to take a weight-neutral or weight-centric approach in your work, the HAES principles offer a compassionate model of care that puts the client at the centre of their healthcare decisions, recognises the broader context of the person beyond the management of their condition, clarifies our responsibilities to practice from an ethical and compassionate standpoint and prioritises health outcomes. Importantly for our professional development, the HAES principles invite us to reflect upon the ways our own personal beliefs about body weight and health may be unintentionally influencing both our work and the way we relate to ourselves. For your clients, a HAES approach may be exactly what they need to overcome hurdles in their path to confident self-management of their condition.
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