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Round and Round: Part 2 —

February 9, 2015

Weight LossFat PoliticsFat HealthFat ScienceExerciseEating DisordersDiet Talk

Trigger warning: Discussion of weight loss, weight and health.

The following is the next part in my series asking Health at Every Size® (HAES) questions about how the social determinants of health (SDH) fits into the HAES model. You can read the first part here.

My apologies for not having this out “tomorrow” as I said at the end of the previous piece, but last Wednesday night I was hit with a fever that was the start of a bout with strep throat that left me unconscious and shivering for two straight days.

What follows is a single question followed by a series of answers from many HAES experts, including Lucy Aphramor and Linda Bacon, whose interview cancellation led to this roundtable in the first place.

Because of the reaction I got to this question from the initial roundtable I assembled, I decided to put the question into a specific context, which resulted in a long setup prior to the actual question. I’m not sure if it was the setup or the question itself, but something triggered a robust response from a number of people who see this issue from different sides.

Although I had intended to ask six questions, but after this question the holidays were right in the thick of when I would have asked the last two. Also, the response to this question was so overwhelming I felt as though it was effective on its own.

And so, without further ado, the final question in the HAES expert roundtable. (Note: I have Americanized the spelling of terms to make this roundtable consistent … sorry non-Americans!)

Big Questions

When I first learned about HAES five years ago, the focus was on evidence-based methods of improving one’s metabolic health by focusing on behaviors rather than weight loss. Lately, I’ve heard from several HAES thought leaders who seem to be distancing HAES from personal lifestyle as the central component. Instead, it seems as if the ubiquitous effects of the social determinants of health have become the heaviest object in the HAES universe.

In Body Respect, there’s reference to the results found in the Whitehall studies, whereby class and status in work environment is directly correlated with the health outcomes of employees. The most shocking detail is that two people can have the exact same healthy lifestyle and the “highest grade” employee will have far better health than the “lowest grade” employee.

And yet, the two-year HAES study clearly showed that a weight-neutral approach to health yielded significantly better long-term outcomes than traditional weight loss approaches. The message was obviously that if you wanted to improve your metabolic health, there were effective weight-neutral ways to do that. So it seems like two low-grade employees at opposite ends of the spectrum in terms of health behaviors would have different long-term health outcomes.

HAES has also very clearly said from the beginning that individual mileage may vary. Those two low-grade employees would have very different reasons for their current lifestyle, healthy or not. The HAES model told both employees that if they wanted to be healthier, then they could do what they were capable of doing and what they were comfortable doing to improve their health. Central to HAES is the idea that we each know what’s best for our mental and physical well-being. This seemed like a natural response to the social determinants of health as well. They’re the macro and micro approaches to health and wellness.

But it feels like something has changed in the emphasis on personal lifestyle choices since the discussion of the SDH has begun in earnest. I just can’t put my finger on it. So here’s the next question:

Question 4: How does the gravity and impact of the social determinants of health affect our understanding of the earlier HAES emphasis on individual health behaviors?

SDH Roadmap

Kerry Beake
Nutritionist and HAES Health Coach

These discussions are good for reflection and consideration. For me, it feels like HAES is changing due to continued research, more awareness of other factors, new people, new ideas. Like any system, the change will differ in rate and uptake based on who, where and what is involved. Personally, I feel that we first need to appreciate what HAES is for us and what it means to us, how it applies to us and, most importantly, how does it help us. Because if we don’t believe it’s helpful and useful then all these discussions become rather pointless.

For sure when I was first stumbled across HAES 7 years ago, it was a revelation and I couldn’t understand why it wasn’t being adopted everywhere. Throughout this journey I have come across many people from many backgrounds and learned new ideas, such as social justice, social determinants of health, intersectionality; I have read (most of my HAES connections are online) about the struggles, the discrimination, the marginalization of the lived experience and learned to understand privilege, especially my own. My capacity to understand these issues has expanded, but it was a journey. So for me the question becomes “How willing are we to keep looking and keep asking questions in order to have a movement that has space for everyone?”

Perhaps I’m less of a philosopher and more of a practical person that my answer is not as in-depth as is needed.

Angela Meadows
Biomedical scientist and PhD candidate

To me, Health At Every Size, by its very name, is about countering the weight-based paradigm and the double standards of healthcare for fat and thin people, and to use a health-centred approach for all people no matter what their body size.

Like many others, when I first discovered HAES, it was a revelation. It was liberating. It gave me agency to do what I could for my own health, within the constraints that still existed within society, my own life, and my own body. The principles told me that no matter what hand I had been dealt, if I wanted to improve my health, I could optimize my outcomes by choosing controllable behaviors — the principles at that time were about accepting size diversity/size acceptance, listening to internal body cues and eating intuitively, and moving for pleasure rather than punishment.

All this was framed within the context of individuality — trusting my body, working with my body, finding what worked for me, which might not be the same as what worked for any given person. This approach gave me hope for the first time and left me feeling liberated rather than defeated.

Separate to that, I became involved in Size Acceptance and anti-weight stigma work. It was always clear to me that fighting for equal rights for people of all sizes was separate from HAES. HAES was about optimizing individual health, and nobody was obliged to do so. Further, whether a person chose to improve their health or not, or was healthy or not, should have no impact on how society treats them. This was a human rights issue, and I separated the social justice aspect of this fight from the individual health concerns. I think both are needed, but that they are not the same. By coupling the weight stigma issue with the “weight is not the be all and end all and health metrics are more meaningful and achievable,” risks moving into a healthist approach to fat people — they’re OK so long as they’re healthy, or trying to be healthy. And for that reason, individual health was always separated from stigma and discrimination work, despite the impact that stigma and discrimination have on health, both directly and indirectly.

I am also aware that for people who are marginalized daily and whose lives are fraught with physical and emotional trauma, intuitive eating is not a high priority. And I know that no matter how much health behavior an individual engages in, social determinants of health (and genetics), will still play a significantly larger part in their well-being and future health outcomes. To me, this does not detract from what I saw as the HAES message — that there are things you can do for yourself that are nurturing rather than destructive, and that these, at least, are within your control.

I think there really do need to be two separate focuses — what individuals can do for themselves and what all of us can do to improve the world we live in.

Lucy Aphramor, PhD, RD
Dietitian and co-author of Body Respect

I wonder if some of the confusion may arise from what gets described as HAES. So, when the trademark holder ASDAH states that HAES must “ground itself in a social justice framework,” then it follows (to me) that something not grounded in this framework isn’t HAES. With this in mind, I know I’ve used the term “HAES” erroneously in the past to describe studies that I now describe as “wellness-centred approaches.” These studies used a weight-equitable approach and taught mindful eating and joyful movement — all the studies had positive outcomes, but they weren’t grounded in social justice, so according to (my reading of) the definition they’re not in fact HAES.

I think it’s quite common for HAES to be (mis)understood as a wellness approach to lifestyle change, one that Individually Orientedembraces compassion and acceptance and that addresses internal and external size stigma. Undoubtedly many people have benefited personally from this message of size awareness and compassionate self-care; it changes lives as people heal from body shame and experience real shifts in their relationship with food, and its impact should not be underestimated … but if it doesn’t also embrace a social justice agenda then it leaves unchanged the thinking that leads to inequality, which unwittingly serves the status quo, and it’s not HAES. Serving the status quo means that the deep structures that lead to stereotype, including size stigma, are reinforced even if we get to moderate the impact in our own lives.

(As an aside while discussing definitions, many of the studies I’m referring to described their approach as HAES as weight-neutral. To me “weight-equitable” better reflects the fact that people of different sizes may well require different treatment for the same outcomes, so being weight-neutral isn’t the most effective framing, in the same way that being gender blind, or race neutral, works against social justice. Deb and Sigrun et. al. used “weight inclusive” in their recent paper … it’s interesting to see how important attention to language is in HAES, and how terms and concepts are evolving all the time.)

Advancing social justice requires more than using a weight-equitable approach to promote health-gain. And if we don’t have social justice we can’t have weight equity; there are no single issues. One way a HAES approach advances social justice is by challenging the narratives that reinforce privilege such as when we offer an accurate, socio-politically aware perspective on the role of lifestyle and non-lifestyle factors in health outcomes. This questions the more common view where health is seen to reside in individuals and metabolic fitness is viewed as within individual control and primarily due to behaviors or access to healthcare. By including social justice, the HAES framework finds room for data and conversation about oppression and privilege, issues often overlooked in critical appraisal of weight science in a wellness approach that isn’t also HAES.

A weight-equitable personal wellness approach can end up bolstering existing power imbalances. When it is blind to the metabolic impact of racism, classism, homophobia, sexism, etc., we can assume it is also unaware of the way that knowledge gets constructed and so inevitably reinforces the unequal power dynamics it is ignorant of. The fact that there is so little awareness of social determinants of health, including among highly-educated practitioners committed to equality, shows how effective dominant discourse is at teaching us both to not see and to believe we are experts at the same time. Moving dialogue forward will take more than adding in biomedical data on social justice to an existing evidence base; it requires us to fix the systems of thought and silencing and abdication to experts that brought us here in the first place. The systems that fuel social injustice are the same systems that fuel weight stigma.

In other words, even with a wellness approach, if we ignore the science on social justice we implicitly uphold (masculinist) ideologies that support the status quo, teach individualism, exclude marginalized voices, and lead to size stereotype. These ideologies don’t get seen as such and the approach is treated as good science, valuable and value-free. This happens at the expense of feminist science, and other ways of knowing that do include marginalized voices and routinely get dismissed as “not valuable” and too biased. “Doing social justice” in HAES is part and parcel of the criticality inherent in unpacking size stigma, not an optional extra. And if we don’t include SDH in health talk we’re using silo-science, it’s not ethical and it infringes practitioner codes of conduct on veracity and best practice in informed consent.

None of this talk of SDH is to detract from the fact that HAES does enhance personal wellness — but by adding in criticality and connectedness to compassion it moves us away from constructing health as a lifestyle commodity to constructing health as something that circulates in relationships along with self-worth, power, resources, privilege, respect and so on in fair societies. The difference is HAES works to enhance personal and collective well-being and recognizes these are always interlinked and influenced by structural factors. Anyone who stands to benefit from self-acceptance, intuitive eating and joyful movement will do so, and those who stand to benefit from the consciousness raising that helps us build a fairer world will also do so.

These days, I think of HAES as a way of helping people “heal the disconnect,” leaving out the social and political realities of our lives and relationships works against this.

In the past I have spent a lot of time defending HAES against charges of being healthist. And it’s true, when I first came across HAES it didn’t seem to offer a socio-politically aware framing and was commonly presented as Size Acceptance/intuitive eating/joyful movement. Like I said earlier, I knew this was really helpful for loads of people, and represents a significant shift in traditional thinking, but to my mind that wasn’t enough to recommend it as it stood. If something is non-relational and ignores inequalities it’s a no-go because it reinscribes privilege and the mindset that creates oppression.

For a time I called my approach “health in every respect” which was HAES + SDH/ relationality, to get away from the emphasis on health behaviors. Of course, I’ve also learnt heaps from what I’ve read in HAES and am hugely grateful to be part of community for support and discussion. Plus, as I’ve read more I’ve come across many HAES advocates and activists who have always challenged the emphasis on individual health behaviours as healthist.

As you’ll have gathered, these days I’d say if it’s healthist (i.e., ignores SDH) then it isn’t HAES, though I know there’s plenty of people doing great work who would disagree with this position.

How does the gravity and impact of the social determinants of health affect our understanding of the earlier HAES emphasis on individual health behaviors?

Here’s the short version — IMO:

If a health program adopts a mechanistic paradigm approach and/or ignores equality issues other than weight equity, then it isn’t HAES, or scientific. If instead it challenges the idea that health outcomes are primarily a result of individual health behaviors by relying on a critical reading of the science and teaching compassionate self-care and relationality, then it’s probably HAES. Many HAES advocates already emphasize this “integrative health” paradigm.

David Spero

If the question is “Is HAES an approach to wellness (for people to use themselves or professionals to use with clients) or is HAES a social movement?” my gut response is that that is too much territory for one concept to hold.

As someone who lives in both the healthcare and social justice worlds, I’m pretty sure health workers can be won to HAES as a wellness approach, though it won’t be at all easy to move them against the weight-centric tide. That would make a huge difference in the lives of millions of fat people.

Getting health workers to embrace a social justice approach to health is a much harder proposition. So combining the two at the level of core principles will slow HAES down in healthcare.

For people outside of healthcare, it seems that whether we include social issues in HAES or don’t include them, we will be excluding a large group. It can’t be helped. My health-promoting self says to put the social issues on a different level. Inform people of them, but don’t require activism as a part of personal health or empowerment. It’s a useful addition but people don’t have to start there. My social activist side says whatever we can do to raise awareness about the social determinants of health is a good thing, so HAES should do that.

There is no right or wrong to this. Both sides are right but seeing things from different points of view. If I got a vote, I’d say keep HAES as primarily a wellness-centered approach. That will continue to bring more people in and help them immediately. Educate people about social issues while they are helping themselves.

Meanwhile, bring HAES science into groups who are already fighting for social approaches to health. Those groups tend to be almost as weight-biased as mainstream public health because they are subject to the same propaganda, but they are the ones experienced and skilled in moving society in a healthier, more just direction.

It’s a difficult question for sure.

Deb Burgard

I am welcoming the discussion, thank you all.

I just want to notice that we are all white people.

Show Me the Data is mostly white people. ASDAH is mostly white people. The Facebook HAES group is mostly white people.

The views presented here debating including the social determinants of health in the model are white people’s views.

The concerns about excluding/distressing/upsetting the people who don’t see the social justice issues as relevant to health are concerns about white people. These issues are not abstractions in the lives of people living with oppression. “Weight stigma” is not a stand-alone concept for bodies that are fat AND Black, fat AND poor, fat AND disabled.

I get it that the HAES-White model works for white people and is the most frictionless set of ideas — for white people.

I just ask us to consider, what about everyone else? We have been given the gift of feedback from people who are not White about the casual racism in our communities, the hypocrisy of saying we want to support health and then contributing to the burden of regular and frequent microaggressions, ignorance of people’s experiences, cluelessness about the impracticality of the model’s emphasis on certain practices that require privilege.

And if that argument isn’t compelling to you, I am sad, but I will appeal to an additional argument: the HAES model has ALWAYS been about the best evidence science can give us. There is no getting around the facts that social support, enough financial resources, and how we are treated by others are the most important determinants of our health. To continue to ignore these scientific facts — as the reductionistic medical model does — is to turn away from addressing the most powerful factors in human well-being.

To me, the challenge is to create communities that give each others lots of support and appreciation (social support!) even as we are trying to learn how to be aware of our privilege and casually-cruel and exclusionary points of view. This is the growing edge.

I have no doubt that the broader population of white people will continue to find the elements of the HAES model they need. Why is this a worry? White people are very good at ignoring what they have the privilege of not caring about. They will do HAES-White. But there needs to be a strong community of people who are making sure that this tool, for what it is worth, is available and relevant to everyone else also.

David Spero

So you are clear that the term HAES should mean a social movement aimed at ending or reducing many forms of oppression and discrimination, forms that have an impact on health. That movement would be a wonderful thing to have. But why is it called HAES? Wouldn’t there be a lot more to the goals of such a movement than just health?

Wouldn’t improved health be a secondary outcome of the social changes the movement would seek to make, most of which have little to do with health or healthcare?

Maybe we should go over all HAES documents, including Linda’s book, to identify passages and practices that might privilege some and exclude others, and change them. And call the movement something else. HAES is the revolutionary concept that any body can be healthy and that all should be treated equally (which might not mean exactly the same, because bodies are different). A movement to tear down racism, sexism, heterosexism, and most of capitalism would be a wonderful thing, and would be good for health. But is it HAES?

As one white person to another, I’m afraid we are not the right ones to answer these questions. Hopefully others will join in.

Linda Bacon, PhD
Nutrition professor, researcher and co-author of Body Respect and Health at Every Size

I think this is an important discussion, and that if we don’t do a better job of integrating the personal with the political, this is the kind of stuff that can make or break our movement. I feel a bit scared for our future, and at times feel disenfranchised from some of the dominant messages I hear in the community (and I include in that a re-reading of some of my own historical work, so I take responsibility here too).

And this is a rarity — I’m so typically on the same page as you Deb, but you lost me here. You suggest that the HAES-White model works for some people, and what I’d like to suggest is that an inclusive model will work even better, not just for POC, but for White people too. I don’t think those of us who are White and/or otherwise privileged need to adopt a social justice model of health just because we’re altruistic caring people and it’s the right thing to do.

The HAES-White model doesn’t work nearly as effectively as a social justice model could for us either. Who among us has 100% privilege (meaning unearned advantages)? And what are the costs to having privilege? I’m pretty high up there on that lucky scale and even I find ways I deviate from the privileged expectations – and can trace the ways they played a role in my developing an eating disorder and other challenges with self-care – and the ways in which that privilege I have is also a burden/challenge. Integrating a social justice perspective allowed me to improve self-care and recover from my eating disorder; without it I would have been mired in self-blame and stuck for so many other reasons. I didn’t make all those steps explicit in my first book – I didn’t even understand it back then — and really regret that now.

People’s stories matter (love this phrasing, which comes from Lucy Aphramor) – and our experience as social beings in an inequitable world needs to be part of healing for ALL of us.

I do hope that people will seriously grapple with these issues. Lucy and I have written about them much more extensively in our book Body Respect. In it, we explicitly show the connections between social justice and health, and how that integration can happen in healthcare/self-care. And I like to think we did it in a very readable and engaging style.

Angela Meadows

I totally understand the significance of SDH — part of my own research and my activism focuses on one aspect of that exactly. I am also aware of the limited impact of personal behavior in the face of the effects of SDH, but I don’t believe this means that individuals cannot act to improve their circumstances.

Yes, I think we need to let people know that their health is massively influenced by the interaction of forces beyond their control, and move away from the personal responsibility argument that people get sick because of their own poor choice. However, a s I noted in my original post, I do believe, and the scientific evidence supports, that within one’s current situation, individual choices are an individual’s best shot at maximizing their outcomes.

I think one of the greatest gifts that HAES has given to so many people is returning their agency, with a concomitant massive increase in well-being. This in turn then often raises awareness of issues of social justice and many people move from that point into activism.I do not believe many of us disagree on the existence of or need to address structural inequalities, or the impact of these on individual and population health. Where there seem to be differences are in what we consider the appropriate FOCUS of HAES. I believe that this should be led by the name itself — Health, Size.

The “more restricted” (if you will) conceptualization of HAES as a non-weight-focused approach to health is simple and can be sold to the people who need to buy it in order to make a difference to the immediate care of millions of individuals. I believe that saying HAES is not HAES unless we address every single social inequality as part of it at this time risks making the message too diffuse to be immediately relevant to almost anybody, derailing ongoing efforts and possibly wiping out what has been achieved so far. By reworking the entire concept of HAES as a social movement seeking to overthrow the kyriarchy, as much as this may need doing, risks HAES disappearing almost entirely from public consciousness, sad though that may be, and make it inaccessible to all but a small group of highly-educated academics and professionals with the energy to pursue it.

Lucy Aphramor

I am glad to have read posts on this issue, thank you all. I’m not sure this adds anything of substance to what has already been posted and I’ve written it mainly for clarification including to acknowledge Angela’s post and respond to my mention in it.

It’s not good enough to leave someone thinking that getting “5 a day” is the best thing they can do for their health when we know health behaviors count for so little of health outcomes.

I’m not exactly sure why this is cited, but yes, absolutely. Which is not the same as saying that self-care is redundant: I have worked with many adults with difficult lives who attended the HAES course “Well Now.” I don’t know if attendance touched local figures on health inequalities or longevity, but I do know it made a huge difference to people’s well-being whether measured in HbA1C or number of Christmas cards given and received.

Putting health behaviors in perspective doesn’t mean throwing the baby out with the bathwater. In fact, I’d say that self-care makes a disproportionate difference to quality of life for disadvantaged groups, and being introduced to the bigger picture of health helps reduce self-blame, increase sense of coherence and sense of agency. I want my work to be rooted in a politics of justice, and this means using a paradigm approach that insists on context and in so doing bridges self-care and social justice. (In saying this I’m not suggesting anything about other people’s work or intent). That’s why I choose to challenge ways of thinking that erroneously conflate health and health behaviors. These reductionist ways of thinking decontextualize lives and silence marginalized voices. A partial reading of the data is also flawed in terms of ethics and scientific quality.

A growing trans-disciplinary movement called Health at Every Size (HAES) shifts the focus from weight management to health promotion. The primary intent of HAES is to support improved health behaviors for people of all sizes without using weight as a mediator; weight loss may or may not be a side effect.

This is from the article I was referring to in my earlier post. These days, I explain that the six randomized controlled trials (RCTs) we referred to as HAES are more accurately described as a wellness approach using intuitive eating/joyful movement and Size Acceptance, and not as HAES RCTs where the ASDAH definition of HAES is “grounded in social justice.” I haven’t reread the article for ages and wasn’t aware we gave this definition of HAES. Speaking for myself, we got this wrong. I think the article is really useful in many ways, but I’ll critique this too now when I refer to it in my own teaching. If I was to rewrite it I’d say something like “the primary intent is to build a society where every body (and explicitly including people of all sizes) is respected and to promote well-being for all by advancing social justice and fostering compassionate self-care.” It will also be useful to reflect on why we didn’t use a definition like this in the first place, particularly as the definition doesn’t reflect the work I was doing at the time.

Challenging size bias per se was a trigger for me to change practice because of the stories I heard as a dietitian in clinic. At the same time, researching links with oppression and health, I realized that Health at Every Size had to start with respect at every size, ethnicity, class, etc.

Generally, the health professionals I speak to have a sense that what they are doing in weight management could be improved; they’re concerned about body dissatisfaction, food preoccupation, the “obesity epidemic,” the implication of high failure rates for patients and their own jobs, and wider factors impacting health. These experiences set the scene for discussing the benefits of HAES as a paradigm shift to health-gain for all sizes etc., within which respect, self-care and equity are understood as integral to health. It’s not been difficult for health professionals to get the revolutionary potential of HAES; and a model of HAES grounded in social justice has been adopted by NHS Highland as integral to their healthy weight policy.

On a personal note, I dislike the way that any disagreement on this issue is deemed to be due to total misunderstanding of what HAES is, possibly due to only reading about it in a book (as per Lucy’s response above),

I’m not sure where this has come from. I get a daily bulletin from Show Me the Data so wrote my response before I had read Angela’s or any of the later posts, that’s why it’s addressed to Shannon. I have reread my post and can’t find anything where I mention books or devalue particular avenues of learning. The question about validity and credibility attached to different forms of knowledge (here the lay vs. academic canon) seems very pertinent to this discussion though. To me, this strongly relates to issues of who/what counts in knowledge creation in the community and very much speaks to the metanarrative of what we’re grappling with at the moment.

For the record, poetry and polemic changed the course of my professional (and personal) life. Having been taught a prescribed form of critical appraisal in formal education, I learnt to interrogate and look beyond this to the criticality that informs my practice — to unlearn to not see/feel — from reading Adrienne Rich, Audre Lorde, ecofeminism, etc. In fact, an integral part of my HAES work is to find different and creative ways to learn, listen and teach so non-scientific contributions are not trivialized as “only” art/experience/lay reading etc.

My understanding of HAES then is as a deep movement that engages with situated knowers and can accommodate the particularity and troublesome knowledge of our lives rather than something beholden to conceptual frameworks that seek universal truths and settle for the dualism of reason and emotion. (Regardless of which, outside of the HAES community, most people still come to me looking for solutions to weight management.)

A deep movement travels some distance from the presenting problem to look for solutions. The presenting problem is often struggles with eating and weight, tied up with personal, professional and political frameworks of judgement rooted in a logic of domination, leading to shame and disconnect. I want to initiate narratives of compassion, criticality and connectedness to foster healing from shame and disconnect, a relational stance which, to my understanding, impacts individual and collective wellbeing.

I am at a loss to grasp how it can be anything other than this (i.e., a social movement), according to the ASDAH definition and notwithstanding points highlighted about health and size in the name.

Having said this, I clearly hear that others, also dedicated to justice and well-being, disagree with me, may see my position as a misunderstanding and/or believe that it is well meant but misguided and even counterproductive with regard to timeliness and effectiveness of message and potential outcomes.

David Spreo

Lucy, maybe it would help to give an example of how you use the social justice framework with a client who comes to you for weight management. What do you do? How does it help? Has it been your experience that learning about the health effects of disempowerment or discrimination or poverty helps people be healthier or happier?

Because in my experience, it often doesn’t work that way. Even if they are helped to cut down on self-blame, people wind up feeling more helpless than they were before. I’ve had people with diabetes tell me, “I’ve already got this terrible disease, and now you’re telling me society is out to get me. What chance do I have?” If you have found good ways to integrate social justice with health on an individual level, that would be great information for HAES and many other social movements and health workers to have.

Linda Bacon

Hi David,

I think your question is best addressed in more detail than I could do in a listserv post. Addressing this question was part of our intent in writing Body Respect. While the whole book is peppered with this info, the last chapter (“Building Body Respect: The Professional Journey”) describes an interaction between a nurse and a client who comes in for diabetes treatment and how it looks different between the two paradigms, noting that “The [HAES] model spans and dovetails the concerns of both self-care and social justice.” The opening paragraph: “For everyone looking to incorporate Body Respect into clinical or social care, let’s return to where we started — contrasting the health impact of personal behaviors like nutrition and lifestyle habits — through the old and new paradigms, Weight Focus and HAES. Consider a hypothetical patient, Janet, newly diagnosed with diabetes.”

Angela – Forgot to mention this earlier, but I remember that one of your concerns was how to frame the incorporation of the social determinants of health in a way that’s palatable and understandable. Know that there’s a long history of people doing this. The Robert Wood Johnson Foundation came out with a good analysis of what works, and made a “messaging guide,” suggestions for framing here.

Lucy Aphramor

Hi David,

It does seems that learning about the impact of circumstance and context on health behavior and outcomes has been helpful to people. Here’s an extract from an article I’ve got under review that sums it up: someone described having an “aha moment” when they were able to make the link between life experiences and poor health (supported by Laura McKibbin’s Food for Thought Pyramid, 2009), circumstances that did not make sense to them within the narrower reductionist lifestyle paradigm they had erstwhile been exposed to.

My experience has been that putting things in context helps people towards a sense of coherence. This might be as simple as saying there’s more to heart disease than diet and activity, to explaining about lifeworld. In practice, the fuller discussions would typically take place in group setting. Certainly there is always the risk of overwhelm, and this is also a very immediate fear for us as practitioners as we come to terms with the limits of lifestyle change and what this means for our own practice too. I find talking about SDH has similarities to helping people manage a whole mix of difficult feelings when first they learn that yo-yo dieting can have health implications. I wonder if it’s the fact we’re working in a philosophy that encourages acceptance/mindfulness which helps people feel they have some choice in their response to reality and that this is significant in moving from despair to resilience. We could also tie the process in to consciousness raising as in other social movements that link the personal and the political.

Linda pointed to a story in Body Respect comparing a consultation with a HAES and non-HAES professional, and there’s a second one in the conclusion that follows “Josie’s” journey and speaks to similar themes.

2 Comments leave one →
  1. Dizzyd permalink
    February 9, 2015 3:30 pm

    I think it comes down to this – that we do what we can with what we have where we’re at; realizing that there are many things that we have to contend with that are beyond our personal control, that we need to band together to push back. That health is a responsibility of society, and shouldn’t just be dumped on the shoulders of those who can least afford to carry it. That health is for everyone, and by that I mean the ability to make your life as livable as you can with support from the health care system that is affordable and personally tailored to your ability to implement it without pushing you beyond reasonable limits and without shaming, and not the luxury enjoyed only by a privileged few.

  2. Len permalink
    February 9, 2015 10:04 pm

    Loads of food for thought here! Shannon, thank you for going to the effort of making this discussion accessible to us. I’d like to comment more but have some hard cogitatin’ to do …

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