'Health at every size' approach shifts the thinking on weight

Spokesperson for Adsa (The Association for Dietetics in South Africa), Nathalie Mat, who is a HAES®-informed registered dietitian says: “The HAES® approach advocates for a weight-neutral approach to addressing health. In other words, how can people change their behaviour to support conditions like diabetes or high blood pressure independent of their weight? It serves to highlight the damage of weight stigma and negative biases that people living in larger bodies face. Imagine going to the doctor with a hereditary condition and being told that the solution is weight loss instead of receiving proper care. This is what happens to people living in bigger bodies. HAES®-informed health professionals understand that there is more to a person than their body size.”

Too often, overweight and obesity is ascribed by a broad spectrum of healthcare practitioners as due to the wilfulness or the failings of their larger patients. This is a view that has been entrenched in the training of medical professionals for many decades. While there is increasing awareness in the medical profession that the causes of obesity are multiple and much more complex than simply over-eating, there’s still a long way to go to weight acceptance. As Mat alludes, it remains a common experience for larger people to be refused medications, physical therapies and even surgeries until they diet and lose weight, depriving them of the same quality of healthcare afforded to slimmer people on the spot. In addition, numerous studies have now shown that this doctor-driven demand for dieting is often ineffective because, while larger people following restrictive diets may well lose weight initially, the longer-term outcomes of the strategy tend to be poor, and they frequently regain the weight. This stressful yo-yo experience has negative impacts on both their mental and physical health with the result that, in time, their experience with the medical fraternity has left them worse off, all-round.

“I believe that the HAES® approach will in time influence public policy due to several factors that have arisen recently. There is a critical mass of research highlighting the ineffectiveness of dietary restriction in the long-term. There is also increasing evidence that weight alone is not the most important determinant of health. As a population, South Africans are talking about inclusion and tolerance more than ever before. I feel that it is the public that will call out health professionals and demand more inclusive treatment, including public healthcare policies.” says Mat.

It's for this reason that some dietitians have become ‘HAES®-informed’. In 2021, a group of South African Dietitians created Non-Diet South Africa. Gayle Landau, also a registered dietitian and certified intuitive eating counsellor says: “The World Health Organisation defines health as a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. I think that the five HAES® principles embrace this definition and provide a holistic framework which can be used to guide practice."

This approach offers patient care that does not centre weight as the main health outcome but rather focusses on behaviours that support mental and physical wellbeing as outcomes. Health at every size provides an alternative narrative to the weight-centric diet approach, and if implemented would hopefully protect those in larger bodies from any weight stigmatisation in the healthcare system.

The HAES® Approach is based on five core principles for healthcare professions:

1. Weight inclusivity – accept and respect the inherent diversity of body shapes and sizes and reject the idealising or pathologising of specific weights.
   
2. Health enhancement – support health policies that improve and equalise 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.

Landau says: “We are proud to say that SA has a growing group of dietitians who regard themselves as Non-Diet Dietitians and are HAES®-informed. The public can connect with us on our Facebook page @nondietSA and we, in turn, can refer them to members who are part of our directory.”

The HAES®, or Health at Every Size, approach is advocated by the Association for Size Diversity and Health (ASDAH), a non-profit organisation with an international membership.