HAES and the healthcare system

In yesterday’s post, I presented observations from Lucy Aphramor, PhD, RD, about how society-wide weight stigma and social disparities contribute to obesity. Social determinants of health, which include income and education level, among other things, are a major focus of public health. Linda Bacon, her co-author on the upcoming book Body Respect, said she has observed a failure to turn words into actions in the spheres of health education and public health. 
“On the one hand, there is a really strong awareness of the social determinants of health, and that’s entering into the discourse a lot, but it’s entering into the discourse independent of the personal responsibility issues. It hasn’t been integrated there,” she said. “So it’s a theoretical model that’s not affected applications in any way. That’s blowing me away—the disconnect.” 
The adherence to the notion of personal responsibility extends to the healthcare system, which Bacon said institutionalizes the weight stigma that’s pervasive in our culture. “It gives us permission to have our discriminatory attitudes,” she said. 
“Even if I knew somebody ate nothing but burgers, it doesn’t give me the right to insult them,” Aphramor said. “My background’s as a dietitian, and I left university thinking it was unacceptable to be fat. There was nothing in my education that helped me to think critically about media messages or the science.” 
Part of the problem, she said is the difficulty of breaking out of reductionist ways of thinking about health. 
“As health practitioners, we’re taught to fix. We’re taught to work within a very narrow paradigm,” Aphramor said, adding that it can be hard to fully accept that the type of science taught is only part of the picture. “It can be a really big thing to recognize that what we’ve been calling scientific practice, if it ignores all the data on social determinants, hasn’t been scientific practice at all.” 
Even harder for health practitioners to accept, she said, is the idea that mainstream methods of addressing obesity could actually be harmful. To do so would force them to come face to face with the limits of their own power. 
“We’re taught, as health professionals, that we’ve got this power to change,” Aphramor said. “[HAES] is a more real position, it makes us more vulnerable as health care practitioners, and it’s not what we’re taught.” 
Bacon said that when she is training physicians in the HAES method, the first thing she usually says to them is, “Think about what advice you would give someone in a thinner body? Now think about what kind of modifications you want to make given the context of [a heavier person’s] person’s body.” 
“We start from a weight-neutral approach, and then the second stage is how do we accommodate this body,” she said. “You don’t tell a fatter person, ‘Go join a gym,’ given the stigma and all that’s involved. You’re going to have to start from their experience, what’s comfortable and safe for them, what’s something they’re going to do.” 
In other words, if a doctor would give advice on strengthening and stretching to a thin person with a knee issue, they shouldn’t just tell an obese person with a knee issue to lose weight. But that’s exactly what happens in many cases. 
 “If what we’re saying is ‘and you should lose weight,’ then what happens then is the person lives in a body they hate, which in itself causes pain, and is more likely to lead to poor self-care behaviors, and shame and blame go along with that,” Aphramor said. “If you’re helping this person to learn to live in a body and accept this body despite the fact it causes pain, it’s a very different thing.” 
“Promoting diets promotes weight stigma, and that’s a problem. It’s a human rights issue. It’s not about effective clinical treatment, it’s about human rights.”
Tomorrow: Health obsession and “body projects”

Photo source: Yale Rudd Center for Food Policy & Obesity