Category: Health at Every Size

Explaining the weight-neutral, anti-diet HAES framework and the science behind it.

  • The Scale Is Changing Your Blood Pressure Reading

    The Scale Is Changing Your Blood Pressure Reading

    The order is always the same. Someone calls your name, walks you to a scale, writes down a number, then sits you down and wraps a cuff around your arm. Weight first, blood pressure second. Nobody picked that sequence for a clinical reason. It is just how the room is laid out.

    A new experiment suggests the sequence has a cost, and that the cost lands on the measurement that actually matters.

    What the study did

    “Please step on the scale”: The experience of being weighed promotes sustained systolic blood pressure levels, by Angela C. Incollingo Rodriguez, L. S. Nunes and M. S. Kirschner, was published as an advance online article in the APA journal Stigma and Health in 2026 (DOI 10.1037/sah0000690).

    190 undergraduates went through a mock health care visit. Everyone gave a baseline blood pressure reading and a saliva sample. Then they were randomised three ways. One group was weighed the standard way, by a researcher, immediately after the baseline. One group weighed themselves alone in a room and typed the number into a form. One group was not weighed at all until every other measurement was finished. Blood pressure and saliva were taken again twenty minutes later.

    Both weighed groups held their systolic blood pressure at the level it started at. The group that was not weighed saw theirs fall over the same twenty minutes. The effect size was Cohen’s f = .30.

    That is the finding, and it is worth being exact about what it is not. There was no difference in diastolic blood pressure. None in cortisol. None in self-reported stress. Baseline systolic readings were already slightly elevated in all three groups, above 120 mmHg, which may say something about walking into a lab or a clinic in the first place.

    The authors’ own summary: being weighed may promote sustained stress physiology outputs via systolic blood pressure, regardless of how weight is measured. Self-weighing did not help. Whatever is happening here does not depend on who holds the clipboard.

    The obvious objection, and why it cuts the other way

    The mean BMI in the sample was 24.29. Participants were young, predominantly white, and from relatively comfortable backgrounds. Most of them were not fat. So the study did not measure what happens to fat patients on a scale.

    The authors say this themselves, and add a point worth sitting with: if the sample was at low risk of having been stigmatised on a scale before, then finding an effect anyway is a more stringent test of the hypothesis, not a weaker one. For people who have been weighed with unsolicited commentary attached, year after year, the prediction is not a smaller effect.

    They also explain why they did not simply recruit higher-weight participants. Deliberately exposing people to something already known to distress them raises an ethical problem they were not willing to wave through. Their proposal is replication with community participants in real clinical settings.

    Until that happens, this is one experiment on 190 students. A reason to look, not a settled fact. And the full text sits behind the publisher’s paywall. What is quoted here comes from the published abstract and impact statement, and from the paper’s conclusions as reproduced at length by Ragen Chastain, who heard the lead author present the work.

    The measurement error that is already documented

    The weighing effect is new and unreplicated. There is a second error in the same room that is neither.

    In 2023, a randomised crossover trial at Johns Hopkins put 195 adults through four rounds of blood pressure measurement and varied only one thing: the cuff. The Cuff(SZ) trial (JAMA Internal Medicine, DOI 10.1001/jamainternmed.2023.3264) found that measuring someone who needs a large cuff with a regular cuff produced a systolic reading 4.8 mmHg too high. For people who need an extra-large cuff, the regular cuff produced a reading 19.5 mmHg too high.

    The second number is not a rounding error. In that group, the average reading taken with the standard cuff was 144/87 mmHg. The same people, measured with the cuff that fit their arm, averaged 125/79 mmHg. Under US guidelines the first number is stage 2 hypertension. The second is not hypertension.

    The authors also show how big the problem is. A national US survey found a regular cuff is the right size for 51 percent of adults; 40 percent need a large one. Most home monitors ship with a single cuff, and it is the regular one.

    Put the two findings in sequence and you get the standard appointment: a fat patient is weighed, then measured with a cuff that does not fit, and the resulting number goes into the file. From there it is read as a fact about the body.

    What follows, and what does not

    None of this is an argument against measuring blood pressure. It is the opposite. Blood pressure is one of the few cheap and genuinely useful things a clinic does. A wrong reading is worse than no reading, because it gets treated as real: more tests, medication decisions, a line in the record that travels with you and shapes what the next doctor assumes before you speak.

    Three things follow from that.

    The order is not fixed. The study authors suggest measuring blood pressure before weighing, or moving the weigh-in to the end of the visit. That costs a practice nothing.

    The cuff has to fit. Arm circumference is measured with a tape at the midpoint between shoulder and elbow, and the cuff is chosen from that number. Guessing by eye is where the 19.5 mmHg comes from.

    A weigh-in is not automatic. Where weight is not needed for a dose, a specific clinical question or a monitoring task, there is no measurement reason to do it. In the US, More-Love.org sells “Don’t Weigh Me” cards for handing over at the desk, precisely because saying it out loud in a waiting room is hard.

    What applies in Germany

    Section 630d of the German Civil Code requires the treating side to obtain the patient’s consent before carrying out a medical measure, and paragraph 3 states that consent may be withdrawn at any time, without giving reasons, and informally. The provision’s core case is an intervention in body or health, and no statute settles whether a routine weigh-in counts as one. But the structure of the German treatment contract is consent, not compliance. Patients agree to measures; they are not subjected to them. Asking to skip the scale, to stand on it facing away, or to have the cuff size checked is a request inside that structure, not obstruction of it.

    Section 630g gives patients the right to inspect their own file. Useful to know, although which cuff was used is almost never recorded.

    What to ask for

    • Blood pressure first, scale afterwards.
    • Upper arm circumference measured with a tape, cuff selected from that number. Above roughly 32 cm, a regular cuff is the wrong one.
    • A second reading after five minutes seated, if the first one is high.
    • If the weight is not needed for a specific clinical purpose, say you would rather skip it. If it is needed, ask to face away from the display and not to be told the number.

    If a practice reacts badly to any of that, our guide to what to do when a doctor blames everything on your weight covers the next steps, and our guide to finding a weight-neutral doctor covers the longer-term one.

    None of this is about whether anyone should weigh less. It is about whether the number in the chart describes the patient or the procedure. Right now, sometimes, it describes the procedure.

    This article does not give medical advice and does not recommend for or against any treatment. Decisions about blood pressure, medication and monitoring belong to you and the people treating you.

  • Health at Every Size, Explained: What HAES Actually Means (and What It Doesn’t)

    Health at Every Size, Explained: What HAES Actually Means (and What It Doesn’t)

    If you have spent any time around body positivity, you have probably seen four letters thrown around as if everyone already agreed on what they mean: HAES, short for Health at Every Size. Some people treat it as a lifestyle. Others treat it as a threat. Most have never read what it actually says.

    This is the long version, and it comes with a correction. When we first published this article, we described HAES using five principles that many websites still list. Those principles are the 2013 version. The Association for Size Diversity and Health (ASDAH), which stewards the framework, replaced them. The current version has four principles and reads very differently. We have rewritten this piece around what the framework says today, and we have gone back to the studies that people cite when they argue about it.

    The one-sentence version

    Health at Every Size is a framework that says your access to respectful, competent healthcare must not depend on your weight, on your willingness to pursue weight loss, or on whether you treat health as a personal goal at all.

    That is narrower than the slogan and more radical than it sounds. It is not a claim that everybody is healthy. It is a claim about who gets care and on what conditions.

    What changed, and why the old five principles are still everywhere

    The name was coined in the late 1990s. ASDAH formed in 2003 and wrote the first set of principles then, drawing on tenets already in circulation from practitioners including Joanne Ikeda, Karen Kratina, Francie Berg and Deb Burgard. The principles were revised in 2013. That 2013 version is the one most of the internet still quotes:

    1. Weight inclusivity
    2. Health enhancement
    3. Respectful care
    4. Eating for well-being
    5. Life-enhancing movement

    They are not wrong, but they are no longer the framework. ASDAH revised the principles again through community surveys and focus groups, and published a Framework of Care developed between 2022 and 2024. On ASDAH’s own page the timing is stated two ways: the introduction says the principles were revised in 2013 and again most recently in 2024, the history section further down dates the third and current revision to 2022 to 2023. We flag the inconsistency rather than pick one, because the exact year is the sort of detail that gets copied wrong for a decade.

    The popular account also over-credits one person. The framework is often attributed to Lindo Bacon, whose 2008 book carried the name to a wide audience. ASDAH’s current materials do not build on any single author, and the named leads of the latest revision are ani janzen, Angel Austin, Veronica Garnett, Da’Shaun Harrison and Pontsho Pilane. If you learned HAES from one book, you learned a version of it that its stewards have since moved past.

    The four principles today

    Paraphrased from ASDAH’s current wording:

    Healthcare is a human right for people of all sizes, including people at the very largest end of the size spectrum. Access to care must not be conditional on reaching a BMI, on pursuing weight loss, or on holding health as a personal value.

    Wellbeing, care and healing are both collective and deeply personal. Health sits on a continuum that shifts with time and circumstance. Community care and mutual aid count. So do clean air, clean water and equitable access to food. Each person is the expert on their own body and gets to decide how much health matters relative to everything else in a life.

    Care is only fully provided when it is free of anti-fat bias and designed with all sizes in mind. When research, policy, education and clinical practice leave out part of the size spectrum, the care built on them is incomplete.

    Health is a sociopolitical construct that reflects the values of a society. How we currently define health carries the marks of white supremacy, anti-Black racism, ableism and healthism. Whatever definition you land on, access to care must never depend on a person’s health status or their compliance with health advice.

    Notice what dropped out. The 2013 list described behaviours: how to eat, how to move. The current list describes conditions of access and the politics of the word health. That is a deliberate narrowing, and it makes the framework harder to sell as a wellness product.

    The Framework of Care, in plain language

    Alongside the principles, ASDAH published a Framework of Care with ten elements, aimed at clinicians rather than at the general public. In short form, a HAES-aligned provider is expected to:

    1. Ground their practice in liberatory frameworks, while recognising that HAES is not itself a liberation movement
    2. Honour patient bodily autonomy, including the right to choose among treatment options
    3. Practise informed consent that names what medicine does not know, not only what it does
    4. Provide compassionate care built on empathy rather than pity
    5. Read weight-related research critically, including the studies behind their own training
    6. Have the skills and the equipment to examine and treat larger bodies competently
    7. Understand their gatekeeping role and use it to reduce harm
    8. Offer tools that support health goals without requiring weight loss
    9. Work on their own anti-fat bias, including fat providers
    10. Work against systemic anti-fat bias in workplaces and policy

    Point 6 is the least abstract and the most telling. A blood pressure cuff that does not fit is not an ideological problem. It is a measurement error that gets written into a chart.

    What the research actually says, including where we got it wrong

    This section used to claim that weight-neutral programmes improve health markers and that in several trials the weight-neutral group kept gains that the diet group lost. The second half of that sentence rests on essentially one trial, and the overall picture is more modest than we made it sound. Here is the evidence, oldest first.

    The flagship trial. Bacon and colleagues (2005) ran a six-month randomised trial with a two-year follow-up: 78 white women aged 30 to 45, described as obese chronic dieters, assigned either to a Health at Every Size programme or to a diet programme. At two years the HAES group had maintained weight and sustained improvements across outcome variables. The diet group had lost weight, improved at one year, then regained the weight, and little of the improvement held. The most striking number is one that rarely gets quoted: 41 percent of the diet group dropped out within six months, against 8 percent of the HAES group. Only half of each group came back for the two-year assessment. A single trial of 78 women from one demographic is a starting point, not a proof.

    The systematic reviews. Clifford and colleagues (2015) reviewed 18 articles covering 16 studies of non-diet interventions and found statistically significant improvements in disordered eating, self-esteem and depression. Just as important for the argument: none of the interventions produced significant weight gain or worsened blood pressure, blood glucose or cholesterol, and in two studies biochemical measures improved compared with the control or diet group. Ulian and colleagues (2018) reviewed 14 papers on HAES-based trials and found benefits for psychological outcomes and physical activity along with changes in eating behaviour, while results for cardiovascular measures, body image and total energy intake were inconsistent. Their conclusion was a call for large long-term trials, not a victory lap.

    The meta-analysis that should temper everyone. Dugmore and colleagues (2020) did the comparison directly: studies that included both a weight-neutral arm and a weight-loss arm. Ten studies met the criteria out of 525 screened. Weight-neutral approaches came out better on one outcome, bulimia, at p = 0.02. On every other outcome, physical, psychological and behavioural, there was no significant difference. Their conclusion is a statement of equivalence: weight-neutral approaches may be as effective as weight-loss approaches. They also note the field’s structural weakness, that weight-neutral and weight-loss are defined differently from study to study and follow-up periods vary.

    What that adds up to. The defensible claim is not that weight-neutral care wins. It is that weight-neutral care performs about as well on health outcomes, does better on disordered eating, and keeps far more people in the room. Given that the alternative asks people to do something that most studies show does not hold long term, equivalence plus retention is not a small result. It is just a different result from the one the slogan implies.

    One more caution, in the interest of not doing to others what we are asking not to have done to us. ASDAH’s own summary of the evidence leans on observational studies suggesting that intentional weight loss is associated with higher mortality in some groups. Observational data of that kind cannot separate deliberate weight loss from illness-driven weight loss, and the causal claim is disputed. We report that ASDAH cites it. We do not repeat it as settled. If you want the longer argument about how funding and framing shape what gets published on weight, we wrote about who pays for weight stigma research.

    HAES in Germany: a word that does not appear

    German-language coverage of HAES is thin, and there is a concrete reason. The authoritative document for how fat people are treated in Germany is the S3 guideline Prävention und Therapie der Adipositas (AWMF register number 050-001), version 5.0, dated 7 October 2024 and valid until October 2029, led by the German Obesity Society. We searched the full 250-page text on 5 August 2026.

    Health at Every Size appears zero times. HAES appears zero times. Gewichtsneutral, the German word for weight-neutral, appears zero times.

    What does appear is stigma: the word stem shows up 123 times, and version 5.0 added an entire new chapter on stigmatisation, chapter 2, based on its own systematic literature search, introduced with the observation that discrimination against fat people in society and in the healthcare system is if anything increasing. The guideline cites a meta-analysis in which 19.2 percent of people with obesity class I and 41.8 percent with class II or III reported weight-based discrimination, against 5.7 percent of people at so-called normal weight. It calls for people-first language and non-stigmatising imagery.

    Then it draws the opposite conclusion from the one HAES draws. The chapter closes by arguing that anti-stigma work should be flanked by public health measures, and that recognising obesity as a disease implies making evidence-based, billable obesity treatment available nationwide over the long term. The guideline’s own benchmark for success elsewhere in the document is a sustained weight loss of at least 5 percent.

    So both frameworks now agree that stigma harms people. They disagree completely about what follows. In the German guideline, destigmatisation is an argument for more treatment and better reimbursement. In HAES, it is an argument for care that does not require treatment as its price of entry. That is not a translation gap. It is a genuine disagreement, and it explains why a German patient can be treated by a doctor who has read a chapter about weight stigma and still be told to come back after losing five percent. We traced the money side of the same question in what France reimburses and Germany does not.

    For readers looking for practical German-language help rather than framework debates: our guides to finding a weight-neutral doctor and finding a weight-inclusive therapist both include what exists in the German-speaking countries, which is very little.

    What HAES is not

    This is where most arguments actually happen, so let us be precise. Several of these are myths that ASDAH itself takes the trouble to debunk.

    HAES does not claim every fat person is healthy. ASDAH’s own answer to that myth is blunt: there are healthy and unhealthy people at every point on the size spectrum, and even if every fat person were unhealthy, they would still deserve quality care.

    HAES does not forbid anyone from changing their own body. Patient autonomy is one of the ten elements of the Framework of Care, and it cuts both ways. The target is coercion and gatekeeping, not individual choices.

    HAES does not ignore illness. It asks that conditions be diagnosed and treated directly instead of being waved away with lose weight first. That is the everyday failure we covered in what to do when a doctor blames everything on your weight.

    HAES is not a social justice movement. This one surprises people on both sides of the argument. ASDAH says so explicitly: HAES is an orientation to health and healthcare that aims to align with liberation movements, not to be one. The overlap with fat liberation is real but they are not the same thing, which is part of why Fat Liberation Month is organised by a different set of people.

    HAES is not body positivity. Body positivity asks you to feel good about your body. HAES makes no demand on your feelings at all. If the distinction interests you, body neutrality sits closer to the HAES position than body positivity does.

    HAES is not anti-health. What it rejects is the assumption that weight and health are the same measurement.

    Why this matters for how you are treated

    The stake is not vocabulary. It is what happens in a fifteen-minute appointment.

    When weight loss is the precondition for care, three things follow. Real conditions get missed, because the differential diagnosis stops at the scale. Patients start avoiding appointments, and avoidance is itself a health risk, one that compounds quietly over years. And people learn to explain their own bodies as personal failure, which is measurable: we looked at the pattern in who blames themselves and who does not, and at what stigma does to mental health in our guide to weight stigma and mental health.

    None of this requires you to adopt a framework. The parts of HAES that would change your care most are the least ideological ones: equipment that fits, a differential diagnosis that does not stop at your weight, and consent that includes what is not known. Where that fails and the failure is legal rather than clinical, our guide to weight discrimination and what to do about it covers the practical routes.

    Frequently asked questions

    Is HAES evidence-based?

    Partly, and the honest answer depends on the claim. That weight-neutral care performs comparably to weight-loss care on health outcomes is supported by a 2020 meta-analysis of ten comparative studies. That it produces better psychological outcomes and better retention has reasonable support. That it is superior across the board does not. The evidence base is small, the definitions are inconsistent, and the largest reviews all end by asking for bigger long-term trials.

    Does HAES mean I should not try to lose weight?

    No. HAES is a position about how healthcare should be provided, not a rule about what you may do with your body. Patient autonomy is written into its Framework of Care. What it opposes is care being withheld until you comply.

    Is HAES the same as intuitive eating?

    No, though they are often bundled. Intuitive eating is a specific approach to eating with its own literature. The 2013 HAES principles included something close to it. The current four principles do not mention eating at all.

    Who decides what counts as HAES?

    ASDAH holds the trademark and publishes both the principles and the Framework of Care. There is no certification body that can stop anyone from using the phrase loosely, which is why HAES-informed on a practice website is a claim, not a credential. Our guide to finding a weight-neutral doctor covers how to check.

    Why does hardly anyone in Germany use the term?

    Because German guideline medicine never adopted it. The 2024 national obesity guideline does not contain the phrase once, while devoting a new chapter to weight stigma. German practitioners have the vocabulary of stigma without the framework that would change what they prescribe.

    The takeaway

    Health at Every Size is not a promise that everyone is fine exactly as they are, and it is no longer the five-point wellness checklist that most of the internet still reproduces. In its current form it is a short, fairly uncomfortable argument about access: that care is a right rather than a reward, that health is a contested word rather than a neutral one, and that a body does not have to shrink before it deserves competent medicine.

    The evidence says weight-neutral care works about as well and loses far fewer people along the way. That is a smaller claim than the slogan and a much harder one to dismiss.

    Fatosphere holds one red line: we do not promote diet or weight-loss products, and we do not publish before-and-after logic. This article reports what research and guidelines say without recommending any weight-loss treatment.

    Sources

    • Association for Size Diversity and Health (ASDAH), Health at Every Size Principles and Framework of Care, asdah.org/haes/, read 5 August 2026.
    • Bacon L, Stern JS, Van Loan MD, Keim NL. Size acceptance and intuitive eating improve health for obese, female chronic dieters. Journal of the American Dietetic Association 2005;105(6):929-936. DOI 10.1016/j.jada.2005.03.011.
    • Clifford D, Ozier A, Bundros J, Moore J, Kreiser A, Morris MN. Impact of non-diet approaches on attitudes, behaviors, and health outcomes: a systematic review. Journal of Nutrition Education and Behavior 2015;47(2):143-155. DOI 10.1016/j.jneb.2014.12.002.
    • Ulian MD, Aburad L, da Silva Oliveira MS, et al. Effects of Health at Every Size interventions on health-related outcomes of people with overweight and obesity: a systematic review. Obesity Reviews 2018;19(12):1659-1666. DOI 10.1111/obr.12749.
    • Dugmore JA, Winten CG, Niven HE, Bauer J. Effects of weight-neutral approaches compared with traditional weight-loss approaches on behavioral, physical, and psychological health outcomes: a systematic review and meta-analysis. Nutrition Reviews 2020;78(1):39-55. DOI 10.1093/nutrit/nuz020.
    • Deutsche Adipositas-Gesellschaft (lead). S3-Leitlinie Prävention und Therapie der Adipositas, AWMF register number 050-001, version 5.0, 7 October 2024, long version, register.awmf.org.

    Publication note: this article was substantially expanded and corrected on 5 August 2026. The previous version described the 2013 principles as current and overstated the comparative evidence.