From time to time the Health At Every Size® Blog shares HAES Matters “roundtable” posts with our readers. The questions below were posed by the ASDAH Blog Committee to some of ASDAH’s HAES experts. We hope you will comment below with your own questions, answers, and reflections on these HAES matters.
Q: I always thought that the HAES approach was about body acceptance and individual behaviors like intuitive eating. Why do the new HAES Principles seem to expand the scope to include social aspects of health?
A: Deb Burgard:
The forces that determine our health are largely big, impersonal structures that support us as humans or make us ill, and allow or prohibit the individual choices that are so often the focus of health models. The HAES model, too, is often spoken of in that individual context, and we wanted to bring that larger focus into view, because racism, sexism, income inequality, access to healthcare, weight stigma, and other major oppressions are such important forces to challenge if we want people to have the chance for greater health. Social justice and health go hand in hand.
A: Fall Ferguson:
I’d like to answer this question from my perspective as the current President of ASDAH, in light of the recent revisions to ASDAH’s HAES Principles.
ASDAH’s 10th anniversary as an organization in 2013 seemed like a good opportunity to reflect on our guiding principles. We found that the core ideas were sound, but no longer enough. In the ten years since our founding, critical perspectives such as healthism, intersectionality, and social justice had emerged as essential to providing effective health care and making good health policy. As I noted in a previous blog post: “We began to realize that our silence on these issues could be interpreted as contributing to such challenges as healthism, ableism, cultural imperialism, and the social determinants of health.”
It is well recognized that social factors such as socioeconomic status, employment status, education, stigma, and others have a profound effect on health outcomes. It is no longer acceptable to focus only on individual behavior change as the primary determinant of health. As the World Health Organization has noted:
“The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.”
In order to promote health for all, we need to recognize that social policies will affect health and act accordingly.
A more detailed set of questions and answers explaining why we have included a broader social perspective in the new HAES Principles may be found on ASDAH’s website.
A: Jessica Wilson:
It is important to understand the direct impact that social aspects have on individual behaviors. When we put them into context, we see that concepts like intuitive eating may look very different to people of different backgrounds.
Promotion of intuitive eating and all of its principles assumes that all people currently have enough food to eat until they’re satisfied and have had enough food in the past to develop typical hunger and fullness cues. Because of differences in socioeconomic status, and access to education and services, this is not universally true. To make the HAES approach relevant for everyone, we need to better understand and acknowledge how our differences impact accessibility to HAES.
This is also why it was important for ASDAH to include language about policy and access in the new principles. These HAES Principles are not a dramatic shift from the originals, but they do set a better intention to understand how our social aspects of health influence an individual’s interaction with the HAES paradigm.
Q: Why is it important to talk about other identities such as race or sexual orientation when talking about the HAES model? Why not just focus on weight?
A: Deb Burgard:
The HAES model is about health, not weight. Health involves addressing all the ways that human beings are oppressed and are therefore kept from being as healthy as they can be. Because the HAES model evolved in part as a response to the weight-biased treatment of higher-weight people, it offers a different process for defining health than BMI, and it offers a pathway back from the harmful interventions and policies around weight policing. But it is not just a reaction that says, “we are not dieting anymore.” It is an ever-evolving attempt to step back and think broadly about what people need to thrive, which opens the conversation to these bigger-picture concerns, especially as the model is claimed by more and more communities.
I think it is also worth thinking about how depending on your intersecting identities, the oppression affecting your health is always more complex than just weight. Having a single-issue focus seems logical if you face a single issue, but if you face weight bias and have any other identities that are stigmatized in this culture, you know that the barriers are multi-dimensional and solving only one will not open the access for you. Most people face intersecting oppressions because they belong to more than one group that faces discrimination.
Finally, it is important to understand the current climate of weight bias in the context of the other structural inequalities in our society. Many people are persuasively arguing that discriminating against higher-weight people is a politically palatable way to enforce class, gender, and race divisions and widen already record-breaking material inequalities, all while seeming to be a “fair” system based on “personal responsibility” for health. It is not an accident that the “war on obesity” takes aim at the same communities as the “war on drugs” – so that the broader conditions that affect people’s lives can be ignored while the dominant group natters on about good/bad food and “people don’t get that they are fat.”
A: Fall Ferguson:
As noted in a recent article highlighting its importance in public health, the perspective or framework known as intersectionality makes the deceptively simple point that:
“multiple social categories (e.g., race, ethnicity, gender, sexual orientation, socioeconomic status) intersect at the micro level of individual experience to reflect multiple interlocking systems of privilege and oppression at the macro, social-structural level (e.g., racism, sexism, heterosexism).”
The infographic shown below illustrates the basic concepts of intersectionality. Applying the framework to health, the various social determinants of health do not operate in isolation from one another. In terms of the HAES approach, weight stigma and size bias affect individuals in the context of their complex, multi-dimensional lives. For individuals who identify with multiple marginalized groups, the effects of stigma and bias may be exponential. We need to take this theoretical framework into account when we do health research and epidemiology, and when we make health policy. Moreover, health practitioners should strive to be aware of the multiple, intersecting identities of their patients and clients.
A: Jessica Wilson: Weight, as well as health, body image, and weight stigma don’t exist in a vacuum; whether people are deemed “overweight,” too fat/thin, “at risk” for heart disease, or “good eaters,” is relative, based on the dominant culture that surrounds them. As someone navigates different cultures, they may be deemed too thin for one and too fat for another. If ASDAH were to discuss weight or weight stigma strictly without acknowledging people’s intersecting identities, this would be a great disservice to all current ASDAH members and reduce the potential reach and capacity of the organization. Additionally, without its commitment to address this topic, ASDAH would likely remain an organization whose membership represents white Western culture and lack the ability to provide support, resources and services to the underrepresented communities in the US and other countries.
Q: The new HAES Principles talk about “the healing power of social connections.” Why is this important?
A: Deb Burgard:
If there is a single recurring finding throughout the health literature, it is the power of our social connections with each other. The security of our bonds offer emotional and practical resources that we need to feel peaceful and hopeful. This is why weight stigma needs to change – but also why it is not nearly enough. In our world we have villages that we form in physical space, in associations of all kinds, and in virtual space, that bring together people from every possible background. We can’t rely on the old idea of us/them, because who is the “them” anymore? That requires skills and wisdom and new institutions that support our connections and shared goals. The forces that want us fighting and judging and snarking and buying products that help us step on the other person’s neck are leading us into a global environmental and social crisis that is not sustainable or survivable. Instead, we have a chance to know each other on a level that other generations could not imagine, to care about each other’s burdens and dreams, to build connections that can organize and leverage the power of many individuals. We stand a chance of surviving, but it will take turning toward each other, doing the hard work of being accountable in our relationships, and working for a fairer future.
A: Fall Ferguson:
We have long known that social connection is an important health indicator. Longitudinal studies on the “Roseto Effect,” for example, demonstrated that groups with strong social connections – family, friends, and community – have lower rates of morbidity and mortality over time compared with similarly situated groups who lack those strong connections. Subsequent studies (such as this 2013 article in BMC Public Health) bear out the importance of social connection to both physical and mental health and emphasize building social capital as a path to increasing well-being and decreasing health inequities.
This principle becomes especially important for the HAES approach in light of the social isolation and stigma that can be a result of size bias and weight stigma. Though not every fat person experiences social isolation, researchers have found that stigma can result in “strained and uncomfortable social interactions, more constricted social networks, a compromised quality of life, low self-esteem, depressive symptoms, unemployment, and loss of income.” This can happen via exclusionary practices by friends, family, employers, and others, or via self-imposed isolation by the stigmatized individual, or both.
Health practitioners should not assume that fat clients are isolated, but when they are, should meet their social isolation with awareness and compassion, and consider how to help them to build social connections that promote deep and sustained well-being.
A: Jessica Wilson:
The HAES approach honors the healing power of social connections. In the US, doctors and other healthcare providers are often seen as the primary individuals with the power to heal, but this is not the case for all nations and communities. What “the healing power of social connections” identifies is the ability and capacity for culture, community, and ourselves us to heal each other. This is a great passage to again illustrate the importance of relationships and how they impact health directly. This passage also gets us away from policing or pathologizing health and weight as something that must be attained through a specific set of actions and we can be open to recognize the diversity in our lived experiences and the strength of different communities to enhance the many facets of health.