What is a Health at Every Size (HAES) Healthcare Provider?
Is it as simple as skipping the scale?
Health and wellness goals can be pursued by all without a focus on weight. Skipping the scale at clinic visits is evidence-based, health-promoting, and most importantly, your choice to make.
A health at every size approach, does not mean we never talk about food, diet or lifestyle, but it does center on several key principles.
5 Principles of Health At Every Size®
Weight Inclusivity. Accept and respect the inherent diversity of body shapes and sizes and reject the idealizing or pathologizing of specific weights.
Health Enhancement
Respectful Care
Eating for Well-being
Life-Enhancing Movement
So what does this look like in practice?
I integrate HAES principles into my practice by acknowledging that most of my patients have received fatphobic OR thincentric care at some point. Both are different sides of the same coin and equally harmful. Patients that don’t meet societal norms with slender and thin bodies have often received subpar healthcare due to weight stigma and been denied medications, physical therapies or referrals unless they just “lost weight” or had all of their symptoms blamed on weight without further inspection. On the other hand, many naturally thin patients are assumed to be healthy without thorough exam and conversation. This results in poorer outcomes for both. Although, patients with higher BMIs are harmed more by fatphobia in medicine through neglect.
Simply put. When providers practice weight bias- it’s lazy medicine.
I support health enhancement by creating a safe space for patients to seek just that! Health goes beyond the scale. How you feel in your body is more important. Focusing on how physical, economic, social, spiritual, and emotional needs are met can have a greater impact on health than a binary scale.
I do not use BMI as the basis for any of my counseling. BMIs are based on bad data, and largely persist in healthcare for the convenience of drug trials and insurance companies. They are one data point of many: cholesterol, blood pressure, weekly activity, sleep quality, mental health, stress, and other lab values matter and are going to fall higher up on my list.
Part of respectful care is simply asking consent. I have patients who have previous experiences of going to a visit to discuss one concern and walking out after an unwanted lecture on weight, and sometimes with their primary concern still unaddressed. I never want to be an example of that type of visit.
On the other hand, I have many patients that have scheduled visits to discuss how to lose weight and it’s central to their goals. I’m happy to have those visits and support you wherever you are in your journey.
If we’re discussing weight and dietary changes, it’s because you’ve asked or given permission for that conversation.
When you disclose a history of disordered eating or patterns, we can talk about that as much as you want. That can also look like us tabling the discussion to another time to avoid triggering behaviors or walking out of a visit feeling worse.
I avoid recommending restrictive diets or avoiding entire food groups unless people have true allergies or reasons to avoid these foods. As a healthcare provider, my initial education in nutrition was subpar. I defer to HAES informed nutritionists, and promote flexible, individualized eating habits and discourage restrictive diets. I discourage restrictive diets because they lack evidence, aren’t sustainable longterm, and can cause metabolic harm in addition to creating unhealthy relationships with food.
I’ll often say: “I don’t prescribe future eating disorders,” and I mean that.
I’ll often say: “I don’t prescribe future eating disorders,” and I mean that. If a “diet” is creating a negative relationship with food or causing you to obsess over meals, that’s concerning! This discussion about food groups and foods to avoid requires some nuance, and there may be specific foods that cause flares or issues , but I would say that any diet that has dozens of foods we can’t eat, certainly has some red flags!
Supporting movement looks like individual goals based on your abilities and interests in a sustainable way that should not enhance shame or suffering. Life enhancing movement is not one size fits all, or prescriptive and should be gradual. It may start at the same time or sometimes after other lifestyle changes have been made. My personal philosophy is just to treat people with compassion and acknowledge that we’re all human.
So what Happens When We Need/Want a Weight?
If you want a weight, great, no worries! Yes. It’s that simple. :)
Here are a few medical indications for checking weights
When a weight based medication is prescribed
An individual is in treatment for an eating disorder (can also be reason for no weights!)
Monitoring for normal growth and development in children
Periodic monitoring during pregnancy to screen for malnutrition or signs of certain pregnancy complications
Concerns with swelling or edema
Tracking longterm changes at annual visits (you can still decline)
You just want a weight recorded in your chart as a baseline
AND it's always optional to get on a scale backwards, or ask a healthcare provider to not say your weight outloud or inform you of scale numbers.
As a healthcare provider, I want to do my part to unpack weight stigma, not enforce it. Weight stigma and bias is enforced by our culture at every level, and I’m committed to continuing to learn and reevaluate my approach.
Resources and references:
Research articles:
Tylka et al. The weight-inclusive versus weight-normative approach to health: Evaluating the evidence for prioritizing well-being over weight loss. Journal of Obesity. July 2014. 1-18.
Bacon and Aphramour. Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutrition Journal. 2011. 10 (9): 2-13.
Flegal et al. Association of all-cause mortality with overweight and obesity using standard body mass index categories: A systematic review and meta-analysis. JAMA 2013. January 2. 309(1): 71-82.
UConn Rudd Center for Food Policy and Obesity Weight Bias Prevention Toolkit: http://biastoolkit.uconnruddcenter.org/
Books:
Linda Bacon. Health at Every Size. 2008.
Linda Bacon and Lucy Aphramour. Body Respect: What Conventional Health Books Get Wrong, Leave Out, and Just Plain Fail to Understand about Weight. 2014.
Other Resources:
Letter for Healthcare providers about weight-inclusive care from Mosaic Comprehensive Care and Lutz and Alexander.
Do Not Weigh Me cards from More-love.org
Cards with Helpful phrases for the doctor’s office, created by Ragen Chastain.
